Healthcare Provider Details

I. General information

NPI: 1871157610
Provider Name (Legal Business Name): LESLIE WALTERS FERGUSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 06/29/2024
Certification Date: 06/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E BROAD ST
RICHMOND VA
23219-1930
US

IV. Provider business mailing address

PO BOX 980257
RICHMOND VA
23298-0257
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-6703
  • Fax: 804-527-4728
Mailing address:
  • Phone: 804-828-9783
  • Fax: 804-828-5613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101274580
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number0101274580
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: