Provider Demographics
NPI:1134589062
Name:WOBIG, LESIE
Entity type:Individual
Prefix:
First Name:LESIE
Middle Name:
Last Name:WOBIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4069 S PACIFIC HWY SPC 132
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-9007
Mailing Address - Country:US
Mailing Address - Phone:541-772-2763
Mailing Address - Fax:541-734-3164
Practice Address - Street 1:777 MURPHY RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8425
Practice Address - Country:US
Practice Address - Phone:541-772-2763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201130024LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse