Healthcare Provider Details

I. General information

NPI: 1154978153
Provider Name (Legal Business Name): CHRISTOPHER LECK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 08/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 EXCELSIOR BLVD
MINNEAPOLIS MN
55426-4702
US

IV. Provider business mailing address

9822 JUNIPER ST NW
COON RAPIDS MN
55433-5439
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-5000
  • Fax:
Mailing address:
  • Phone: 651-808-4785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number238722-6
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: