Provider Demographics
NPI:1235123126
Name:WISCOMBE, LESLIE K (DO)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:K
Last Name:WISCOMBE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 E 66TH TER
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133-5251
Mailing Address - Country:US
Mailing Address - Phone:816-737-1037
Mailing Address - Fax:816-737-0477
Practice Address - Street 1:10000 E 66TH TER
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-5251
Practice Address - Country:US
Practice Address - Phone:816-737-1037
Practice Address - Fax:816-737-0477
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100001310FMedicaid
MO240345017Medicaid
MO1235123126Medicaid
KS100001310EMedicaid
KS100001310DMedicaid
KSP012434AMedicare PIN
MO240345017Medicaid
KS100001310DMedicaid
MOT37000004Medicare PIN
MOP012434Medicare PIN
KS100001310EMedicaid