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General NPI Number Information
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NPI Number | 1790053569
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Entity Type | Individual
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Provider Name | LESLIE RAY WALTMAN III CRNA
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Gender | Male
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Dates
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Enumeration Date | 12/08/2011
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Last Update Date | 02/19/2018
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Provider Practice Location Address
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Address Line | 8717 W 110TH ST SUITE 600
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City | OVERLAND PARK
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State | KS
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Zip | 66210-2144
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Country | US
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Telephone | 205-474-3208
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Fax |
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Provider Business Mailing Address
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Address Line | 1308 E BRIGGS DR
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City | MACON
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State | MO
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Zip | 63552-1919
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Country | US
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Telephone | 660-415-5215
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 1-115596
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License Number State | AL
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 2012006261
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License Number State | MO
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Taxonomy #3
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 2011040586
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License Number State | MO
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