Healthcare Provider Details

I. General information

NPI: 1992780712
Provider Name (Legal Business Name): LESLIE GLEN MASSOGLIA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LESLIE GLEN AHLERS MD

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4845 SAFARI CT N
EAGAN MN
55122-2617
US

IV. Provider business mailing address

4845 SAFARI CT N
EAGAN MN
55122-2617
US

V. Phone/Fax

Practice location:
  • Phone: 507-461-3813
  • Fax: 952-431-5334
Mailing address:
  • Phone: 507-461-3813
  • Fax: 651-305-0595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number43602
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number43602
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number43602
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number43602
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: