Healthcare Provider Details

I. General information

NPI: 1275913824
Provider Name (Legal Business Name): LESLIE A HASS AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 POLK ST STE F
TWIN FALLS ID
83301-4864
US

IV. Provider business mailing address

3704 N 2200 E
FILER ID
83328-5260
US

V. Phone/Fax

Practice location:
  • Phone: 208-751-9708
  • Fax: 208-736-0890
Mailing address:
  • Phone: 208-751-9708
  • Fax: 208-736-0890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberNP-1571A
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP-1571A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: