Basic Information
| Provider Information | |||||||||
| NPI: | 1265620918 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERKI-MASON | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2925 BRIARPARK DR STE 575 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770423776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8326262842 | ||||||||
| FaxNumber: | 8326262842 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 US 79 W | ||||||||
| Address2: | STE 100 | ||||||||
| City: | HUTTO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817838162 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2007 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA12200 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 363176743 | 01 | IL | TAX ID | OTHER |