Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 038004891 | IL |
Y | 111NI0900X | Internist | 038004891 | IL |
N | 111NN0400X | Neurology | 038004891 | IL |
NPI | 1235279548 |
---|---|
Provider Name | Dr. Timothy Bryan Leasenby |
First Address | Aurora, IL 60504-4105 |
Second Address | Aurora, IL 60504-4105 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2007 |
Last Update Date | 06/04/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T05703 | (02) | IL |