Basic Information
| Provider Information | |||||||||
| NPI: | 1821196700 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEDESMA | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3421 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192727303 | ||||||||
| FaxNumber: | 3192727318 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 8TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | OELWEIN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506622447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192836000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 04/05/2010 | ||||||||
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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 | 207P00000X | A080263 | IA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 363L00000X | A080263 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | A080263 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 364SE0003X | A080263 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Emergency | 363LC1500X | A080263 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 0074625 | 05 | IA | MEDICAID |