Basic Information
| Provider Information | |||||||||
| NPI: | 1811343544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASHATKO | ||||||||
| FirstName: | LESLEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | STEMPER | ||||||||
| OtherFirstName: | LESLEY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 110 E 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | ANTIGO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544092710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156232351 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 110 E 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | ANTIGO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544092710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156232351 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2016 | ||||||||
| LastUpdateDate: | 06/14/2016 | ||||||||
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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 | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.