1396732814 NPI number — LESLIE C DOBBS CRNA

Table of content: LESLIE C DOBBS CRNA (NPI 1396732814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396732814 NPI number — LESLIE C DOBBS CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOBBS
Provider First Name:
LESLIE
Provider Middle Name:
C
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:
1396732814
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30585
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87190-0585
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-243-7729
Provider Business Mailing Address Fax Number:
505-243-4804

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4401 MASTHEAD ST NE
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87109-4493
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-243-7729
Provider Business Practice Location Address Fax Number:
505-243-4804
Provider Enumeration Date:
09/29/2005

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:  R39298 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: K3941 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".