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General NPI Number Information
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NPI Number | 1245790385
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Entity Type | Individual
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Provider Name | ANA ALICIA LEONSO BRAVO MD
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Gender | Female
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Dates
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Enumeration Date | 03/24/2019
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Last Update Date | 10/16/2024
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Provider Practice Location Address
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Address Line | 601 W COUNTRY CLUB RD STE 102
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City | ROSWELL
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State | NM
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Zip | 88201-5227
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Country | US
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Telephone | 505-272-1312
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Fax |
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Provider Business Mailing Address
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Address Line | 800 BRADBURY DR SE STE 116
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City | ALBUQUERQUE
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State | NM
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Zip | 87106-4310
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Country | US
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Telephone | 505-272-1476
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | MD2024-0962
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License Number State | NM
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