Healthcare Provider Details

I. General information

NPI: 1811971690
Provider Name (Legal Business Name): IVAN LEGOAS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7150 CLEARVISTA DR
INDIANAPOLIS IN
46256-1695
US

IV. Provider business mailing address

11344 ABBITT TRL
ZIONSVILLE IN
46077-0016
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-5890
  • Fax:
Mailing address:
  • Phone: 574-268-9640
  • Fax: 574-268-0684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28139740A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: