Provider Demographics
NPI:1427032812
Name:OLSON, LESLIE GULLAHORN (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:GULLAHORN
Last Name:OLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:JOAN
Other - Last Name:GULLAHORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:2823 FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1324
Practice Address - Country:US
Practice Address - Phone:559-459-4004
Practice Address - Fax:559-459-5029
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24897207X00000X
PAMD482935207X00000X
CAA76986207XX0801X, 207X00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ833146Medicaid
AZZ144059Medicare PIN
CAI00544Medicare UPIN
CA0443010001Medicare NSC