Provider Demographics
NPI:1205847316
Name:WIZAUER, LESLIE A (CRNA)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:A
Last Name:WIZAUER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12198 MANTAWAUKA DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-8853
Mailing Address - Country:US
Mailing Address - Phone:810-964-7756
Mailing Address - Fax:
Practice Address - Street 1:12198 MANTAWAUKA DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-8853
Practice Address - Country:US
Practice Address - Phone:810-996-4775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106426367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101850691Medicaid
MI0B56166OtherBLUE SHIELD
MI101850691Medicaid