=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699761700
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE T MCQUISTON MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2005
-----------------------------------------------------
Last Update Date | 10/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 BARBARA JORDAN BLVD SUITE 302
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78723-3077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-472-6134
-----------------------------------------------------
Fax | 512-472-2928
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 BARBARA JORDAN BLVD SUITE 302
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78723-3077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-472-6134
-----------------------------------------------------
Fax | 512-472-2928
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2088P0231X
-----------------------------------------------------
Taxonomy Name | Pediatric Urology Physician
-----------------------------------------------------
License Number | M0174
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | M1074
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------