Basic Information
| Provider Information | |||||||||
| NPI: | 1306864145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STINNETT | ||||||||
| FirstName: | LEO | ||||||||
| MiddleName: | GASTON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 N GRAND AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | NOGALES | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856211061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207612133 | ||||||||
| FaxNumber: | 5202811112 | ||||||||
| Practice Location | |||||||||
| Address1: | 1209 W TARGET RANGE RD | ||||||||
| Address2: | |||||||||
| City: | NOGALES | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856212466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202874747 | ||||||||
| FaxNumber: | 5202853136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 05/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | J0285 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 27159 | AZ | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 454835 | 05 | AZ | MEDICAID |