Provider Demographics
NPI:1093799132
Name:HAGENSTEIN, LESLIE (DNP, APRN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:HAGENSTEIN
Suffix:
Gender:F
Credentials:DNP, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX E
Mailing Address - Street 2:9615 HWY 191
Mailing Address - City:PINEDALE
Mailing Address - State:WY
Mailing Address - Zip Code:82941-3040
Mailing Address - Country:US
Mailing Address - Phone:307-231-9562
Mailing Address - Fax:307-276-3024
Practice Address - Street 1:103 W 3RD STREET
Practice Address - Street 2:NEW PHYSICAL ADDRESS
Practice Address - City:MARBLETON
Practice Address - State:WY
Practice Address - Zip Code:83113
Practice Address - Country:US
Practice Address - Phone:307-276-3306
Practice Address - Fax:307-276-3024
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8665.0048363LF0000X
AK340363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY124348900Medicaid
WYR14678Medicare UPIN
WY20905Medicare PIN