Provider Demographics
NPI:1144787136
Name:LASTRA, LEYLA AILEEN M (SURGICAL ASSISTANT)
Entity Type:Individual
Prefix:
First Name:LEYLA
Middle Name:AILEEN M
Last Name:LASTRA
Suffix:
Gender:F
Credentials:SURGICAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 CLONMORE CT
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-4016
Mailing Address - Country:US
Mailing Address - Phone:909-254-3276
Mailing Address - Fax:
Practice Address - Street 1:1143 CLONMORE CT
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-4016
Practice Address - Country:US
Practice Address - Phone:909-254-3276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical