Provider Demographics
NPI:1295519601
Name:WAGNER, LESLIE DAWN
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:DAWN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 S WESTERN AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-2997
Mailing Address - Country:US
Mailing Address - Phone:405-691-5434
Mailing Address - Fax:405-692-3703
Practice Address - Street 1:10001 S WESTERN AVE STE 102
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-2997
Practice Address - Country:US
Practice Address - Phone:405-691-5434
Practice Address - Fax:405-692-3703
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TA841225200000X
OK841225200000X
OKTA841225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant