Provider Demographics
NPI:1477061836
Name:BELUS, LEESA MARIE (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:LEESA
Middle Name:MARIE
Last Name:BELUS
Suffix:
Gender:F
Credentials:AGACNP-BC
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 327
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-0327
Mailing Address - Country:US
Mailing Address - Phone:307-620-9623
Mailing Address - Fax:
Practice Address - Street 1:1842 SUGARLAND DR STE 103
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-5719
Practice Address - Country:US
Practice Address - Phone:307-673-4960
Practice Address - Fax:307-673-4951
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY15089-1709363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care