Basic Information
| Provider Information | |||||||||
| NPI: | 1093859654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORTLAND | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CENTRACARE CIR # 1300 | ||||||||
| Address2: | CENTRACARE CLINIC HEALTH PLAZA PEDIATRIC AND ADOLESCENT | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543610 | ||||||||
| FaxNumber: | 3206543647 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIR # 1300 | ||||||||
| Address2: | CENTRACARE CLINIC HEALTH PLAZA PEDIATRIC AND ADOLESCENT | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543610 | ||||||||
| FaxNumber: | 3206543647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 12/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | TRN9066 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 53414 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0207X | 55982 | WI | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | 208000000X | 49019 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.