Provider Demographics
NPI:1730294273
Name:BRASEL, LESLIE E (D PH)
Entity Type:Individual
Prefix:MR
First Name:LESLIE
Middle Name:E
Last Name:BRASEL
Suffix:
Gender:M
Credentials:D PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1801 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-3942
Mailing Address - Country:US
Mailing Address - Phone:918-756-3334
Mailing Address - Fax:918-756-4949
Practice Address - Street 1:1125 E CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4641
Practice Address - Country:US
Practice Address - Phone:918-224-9310
Practice Address - Fax:918-224-9036
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7137183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist