Healthcare Provider Details

I. General information

NPI: 1891299699
Provider Name (Legal Business Name): LESHAWN TANKSLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 03/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 SILVERTON PL
PISCATAWAY NJ
08854-1479
US

IV. Provider business mailing address

522 SILVERTON PL
PISCATAWAY NJ
08854-1479
US

V. Phone/Fax

Practice location:
  • Phone: 908-425-5683
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number32W101197700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: