Basic Information
| Provider Information | |||||||||
| NPI: | 1174787790 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLINGHAM | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5055 E BROADWAY BLVD | ||||||||
| Address2: | A100 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857113640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203270460 | ||||||||
| FaxNumber: | 5207950225 | ||||||||
| Practice Location | |||||||||
| Address1: | 5555 E 5TH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857112415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208864181 | ||||||||
| FaxNumber: | 5207217536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2008 | ||||||||
| LastUpdateDate: | 10/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 44577 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | Z146300 | 01 | AZ | MEDICARE PTAN | OTHER |