Provider Demographics
NPI:1487933982
Name:LESNAR, CASEY ALLEN
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:ALLEN
Last Name:LESNAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 S SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-4207
Mailing Address - Country:US
Mailing Address - Phone:605-221-0782
Mailing Address - Fax:605-221-0839
Practice Address - Street 1:1720 S SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-4207
Practice Address - Country:US
Practice Address - Phone:605-221-0782
Practice Address - Fax:605-221-0839
Is Sole Proprietor?:No
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5402183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist