Basic Information
| Provider Information | |||||||||
| NPI: | 1770041766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNOW | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | LYNNE | ||||||||
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| Credential: | CRAY TECH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16690 HIGHWAY 14 | ||||||||
| Address2: | |||||||||
| City: | MARIONVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657057154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792446435 | ||||||||
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| Practice Location | |||||||||
| Address1: | 325 MAINE ST LAWRENCE, KS 66044 | ||||||||
| Address2: | |||||||||
| City: | LAWERENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855055000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2019 | ||||||||
| LastUpdateDate: | 03/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 201754 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.