Healthcare Provider Details

I. General information

NPI: 1427002260
Provider Name (Legal Business Name): ELAINE LESLIE BRENT MS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 REID ST ATTN: MDHJ QCR, MADIGAN ARMY MEDICAL CENTER
TACOMA WA
98431-1100
US

IV. Provider business mailing address

9040 REID ST ATTN: MDHJ QCR, MADIGAN ARMY MEDICAL CENTER
TACOMA WA
98431-1100
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2252
  • Fax: 253-968-3278
Mailing address:
  • Phone: 253-968-2252
  • Fax: 253-968-3278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number19500
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: