Basic Information
| Provider Information | |||||||||
| NPI: | 1154623015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ORTIZ | ||||||||
| FirstName: | LESLY | ||||||||
| MiddleName: | TATIANA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REYES | ||||||||
| OtherFirstName: | LESLY | ||||||||
| OtherMiddleName: | TATIANA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 501 S SANTA FE AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SALINA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858231032 | ||||||||
| FaxNumber: | 7854527807 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S SANTA FE AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SALINA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858231032 | ||||||||
| FaxNumber: | 7854527807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2010 | ||||||||
| LastUpdateDate: | 03/04/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 15-02211 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 15-02211 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 201243810A | 05 | KS | MEDICAID |