=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598383929
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRISTINA LEON, DO PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2020
-----------------------------------------------------
Last Update Date | 07/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | IDAHO FALLS PEDIATRICS 3067 EAGLE DR
-----------------------------------------------------
City | AMMON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-251-5247
-----------------------------------------------------
Fax | 208-820-7004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9927 WEST GIBSON JACK ROAD
-----------------------------------------------------
City | POCATELLO
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-251-5247
-----------------------------------------------------
Fax | 208-820-7004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CRISTINA LEON
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 208-251-5247
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0202X
-----------------------------------------------------
Taxonomy Name | Pediatric Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------