Provider Demographics
NPI:1689924698
Name:HEGGEN, LESLIE NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:NICOLE
Last Name:HEGGEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 INDIAN SCHOOL RD NE STE 110
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3991
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6701 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4318
Practice Address - Country:US
Practice Address - Phone:505-727-6200
Practice Address - Fax:505-727-9590
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1068363AM0700X
NMPA2019-0018363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDA0514Medicaid