Provider Demographics
NPI:1982836433
Name:LESLEY, NATHAN EDWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:EDWIN
Last Name:LESLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-877-3277
Mailing Address - Fax:817-877-3280
Practice Address - Street 1:5612 EDWARDS RANCH RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4145
Practice Address - Country:US
Practice Address - Phone:817-420-9238
Practice Address - Fax:817-357-4363
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0921207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01021883OtherRAILROAD MEDICARE
TX285881301Medicaid