Healthcare Provider Details

I. General information

NPI: 1952876070
Provider Name (Legal Business Name): LESLIE ASTON WATTKIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 CLINT MOORE RD
BOCA RATON FL
33487-2768
US

IV. Provider business mailing address

1601 CLINT MOORE RD STE 9
BOCA RATON FL
33487-2768
US

V. Phone/Fax

Practice location:
  • Phone: 561-939-0208
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number9411334
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: