Healthcare Provider Details

I. General information

NPI: 1942596341
Provider Name (Legal Business Name): NICHOLAS S LESLEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 12/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 FAWCETT AVE STE 100
TACOMA WA
98402-1900
US

IV. Provider business mailing address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

V. Phone/Fax

Practice location:
  • Phone: 253-761-4200
  • Fax: 253-761-4201
Mailing address:
  • Phone: 207-662-7060
  • Fax: 207-662-7066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD183728
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD60757715
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: