Healthcare Provider Details

I. General information

NPI: 1245790385
Provider Name (Legal Business Name): ANA ALICIA LEONSO BRAVO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2019
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W COUNTRY CLUB RD STE 102
ROSWELL NM
88201-5227
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-1312
  • Fax:
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD2024-0962
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: