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General NPI Number Information
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NPI Number | 1609068352
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Entity Type | Organization
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Legal Business Name | FREDERICK D LEIST MD INC PS
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Dates
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Enumeration Date | 08/16/2007
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Last Update Date | 10/11/2007
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Provider Practice Location Address
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Address Line | 2600 CHERRY AVE SUITE 201
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City | BREMERTON
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State | WA
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Zip | 98310-4213
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Country | US
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Telephone | 360-479-4370
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Fax | 360-792-1166
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Provider Business Mailing Address
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Address Line | 2600 CHERRY AVE SUITE 201
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City | BREMERTON
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State | WA
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Zip | 98310-4213
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Country | US
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Telephone | 360-479-4370
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Fax | 360-792-1166
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | MS. SUZANNE M FLETCHER
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Credential |
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Telephone | 360-479-4370
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MD00010979
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License Number State | WA
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