Basic Information
| Provider Information | |||||||||
| NPI: | 1205828324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENTEN | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | SIERRA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 98146 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276248146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194207811 | ||||||||
| FaxNumber: | 9194207815 | ||||||||
| Practice Location | |||||||||
| Address1: | 612 MOCKSVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281442732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042105078 | ||||||||
| FaxNumber: | 7042105395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 09/24/2007 | ||||||||
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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 | 207ZP0102X | 34465 | NC | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 897615B | 05 | NC | MEDICAID |