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NPI Code Detail

MEDICARE: MARK S LEATH CRNA

MEDICARE: MARK S LEATH CRNA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1367500000XCertified Registered Nurse AnesthetistAP05050LA
2367500000XCertified Registered Nurse AnesthetistC01511AR

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
35Y301OTHERARBCBS

General Provider Information

NPI Number : 1871573014
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARK S LEATH CRNA
Provider Business Mailing Address
First Line : PO BOX 3185
Second Line :
City : MONROE
State : LA
Zip : 71210-3185
Country : US
Telephone Number : 318-998-6129
Fax Number :
Provider Business Practice Location Address
First Line : 4864 JACKSON ST
Second Line :
City : MONROE
State : LA
Zip : 71202-6400
Country : US
Telephone Number : 318-330-7626
Fax Number : 318-330-7648
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/21/2006
Last Update Date : 08/28/2017

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