1710983515 NPI number — LESLIE A. BOYD-LONG CRNA

Table of content: LESLIE A. BOYD-LONG CRNA (NPI 1710983515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710983515 NPI number — LESLIE A. BOYD-LONG CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOYD-LONG
Provider First Name:
LESLIE
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710983515
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5865
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79408-5865
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-743-2898
Provider Business Mailing Address Fax Number:
806-743-2787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3014 104TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79423-6088
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-745-1656
Provider Business Practice Location Address Fax Number:
806-743-2984
Provider Enumeration Date:
06/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  135111 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 85130U . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 85131U . This is a "HMO BLUE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 93580584 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 93524 . This is a "PRESBYTERIAN COMMERCIAL" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 93524 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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