Healthcare Provider Details

I. General information

NPI: 1871573014
Provider Name (Legal Business Name): MARK S LEATH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2006
Last Update Date: 08/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4864 JACKSON ST
MONROE LA
71202-6400
US

IV. Provider business mailing address

PO BOX 3185
MONROE LA
71210-3185
US

V. Phone/Fax

Practice location:
  • Phone: 318-330-7626
  • Fax: 318-330-7648
Mailing address:
  • Phone: 318-998-6129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP05050
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC01511
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: