=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760790612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE N BROWN P.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2010
-----------------------------------------------------
Last Update Date | 01/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 79 WAWECUS ST STE. 101
-----------------------------------------------------
City | NORWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06360-2160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-886-2655
-----------------------------------------------------
Fax | 860-886-2655
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 79 WAWECUS ST STE. 101
-----------------------------------------------------
City | NORWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06360-2160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-886-2655
-----------------------------------------------------
Fax | 860-886-2655
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 002505
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 002505
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------