Provider Demographics
NPI:1669002978
Name:LEISTNER, CHARLES J III (APRN)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:LEISTNER
Suffix:III
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 E 1485 RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66046-9265
Mailing Address - Country:US
Mailing Address - Phone:785-917-1866
Mailing Address - Fax:
Practice Address - Street 1:776 E 1485 RD
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66046-9265
Practice Address - Country:US
Practice Address - Phone:785-917-1866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-26
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-79245-121363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily