Provider Demographics
NPI:1952433674
Name:BALDERSTON, LESLIE ANN (FNP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:BALDERSTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 SW OAK ST.
Mailing Address - Street 2:STE. 210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204
Mailing Address - Country:US
Mailing Address - Phone:503-988-3663
Mailing Address - Fax:503-988-3015
Practice Address - Street 1:619 NW 6TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3964
Practice Address - Country:US
Practice Address - Phone:503-988-3674
Practice Address - Fax:503-988-5780
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR082010783N1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22959Medicaid
ORR0000WCJHTMedicare Oscar/Certification