Healthcare Provider Details

I. General information

NPI: 1366479032
Provider Name (Legal Business Name): STEPHEN A. LESLIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIRCLE CENTRACARE CLINIC- WOMEN'S & CHILDRENS
ST CLOUD MN
56303-5000
US

IV. Provider business mailing address

1900 CENTRACARE CIRCLE CENTRACARE CLINIC- WOMEN'S & CHILDRENS
ST CLOUD MN
56303-5000
US

V. Phone/Fax

Practice location:
  • Phone: 320-654-3630
  • Fax:
Mailing address:
  • Phone: 320-654-3650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number51744
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: