Provider Demographics
NPI:1780835504
Name:LEONARD, ROGER L (RN)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:L
Last Name:LEONARD
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87052
Mailing Address - Country:US
Mailing Address - Phone:505-465-3060
Mailing Address - Fax:
Practice Address - Street 1:#85 WEST HWY 22
Practice Address - Street 2:
Practice Address - City:SANTO DOMINGO
Practice Address - State:NM
Practice Address - Zip Code:87052
Practice Address - Country:US
Practice Address - Phone:505-465-3060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR54222261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service