Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 9582-33 | WI |
NPI | 1275174922 |
---|---|
Provider Name | Mrs. Leslie Ann Las |
First Address | Tomah, WI 54660 |
Second Address | Tomah, WI 54660 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/10/2019 |
Last Update Date | 03/10/2019 |