Basic Information
| Provider Information | |||||||||
| NPI: | 1922480193 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAKACS | ||||||||
| FirstName: | LESLIE | ||||||||
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| NamePrefix: | MR. | ||||||||
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| Credential: | AA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3431 ANDERSON AVE SE | ||||||||
| Address2: | APT C | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9079808830 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | MSC 10 6000 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722610 | ||||||||
| FaxNumber: | 5052721300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2015 | ||||||||
| LastUpdateDate: | 08/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | AA2015-002 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.