Provider Demographics
NPI:1164984563
Name:WAGUESPACK, LESLIE B (PA-C)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:B
Last Name:WAGUESPACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:M
Other - Last Name:BURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7777 HENNESSY BLVD STE 2003B
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:225-765-7163
Mailing Address - Fax:225-765-7164
Practice Address - Street 1:5000 HENNESSY BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808
Practice Address - Country:US
Practice Address - Phone:225-765-7163
Practice Address - Fax:225-765-7164
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA320038363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant