Healthcare Provider Details

I. General information

NPI: 1265064612
Provider Name (Legal Business Name): ROBERT LEYSAHT APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10408 N CENTERWAY DR
PEORIA IL
61615-1234
US

IV. Provider business mailing address

313 MONTEREY DR
WASHINGTON IL
61571-2946
US

V. Phone/Fax

Practice location:
  • Phone: 309-308-5100
  • Fax:
Mailing address:
  • Phone: 309-256-9485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209020786
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: