Basic Information
| Provider Information | |||||||||
| NPI: | 1417184771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LESHANSKI | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | MCCLANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 407 | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304750407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125355581 | ||||||||
| FaxNumber: | 9125355457 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304744770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125388484 | ||||||||
| FaxNumber: | 9125388665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2009 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0102202657 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | OS14200 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | 081732 | GA | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | OS14200 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 208000000X | 081732 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.