Provider Demographics
NPI:1487641957
Name:WONG, LESLIE P (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:P
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:PAK YIN
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5169 S COTTONWOOD ST STE 320
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6768
Practice Address - Country:US
Practice Address - Phone:801-507-2531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043067207RN0300X
CAC54492207RN0300X
UT12745135-1205207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8392490Medicaid
WA186164OtherL I
WA186164OtherL I
WAP00156796Medicare ID - Type UnspecifiedRR
WAP00150872Medicare ID - Type UnspecifiedRR
WA8802843Medicare ID - Type Unspecified