=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295895845
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE BRANT HOLBROOK LSA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 09/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1822 W BRAKER LN # 81603
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78758-3606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-973-9222
-----------------------------------------------------
Fax | 512-777-4527
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1822 W BRAKER LN # 81603
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78758-3606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-973-9222
-----------------------------------------------------
Fax | 512-777-4527
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZS0410X
-----------------------------------------------------
Taxonomy Name | Surgical Technologist
-----------------------------------------------------
License Number | F01368
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number | SA00042
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------