Healthcare Provider Details

I. General information

NPI: 1902974991
Provider Name (Legal Business Name): LEON R NIELSEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W 2ND ST
GOODLAND KS
67735-1602
US

IV. Provider business mailing address

810 BEAVER DR
GOODLAND KS
67735-9781
US

V. Phone/Fax

Practice location:
  • Phone: 785-890-3625
  • Fax:
Mailing address:
  • Phone: 785-899-6368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number54087
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: