Healthcare Provider Details

I. General information

NPI: 1396285862
Provider Name (Legal Business Name): LEON BULLOUGH CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2017
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 ANDERSON ST SUITE 101
PITTSBURGH PA
15212-5803
US

IV. Provider business mailing address

127 ANDERSON ST SUITE 101
PITTSBURGH PA
15212-5803
US

V. Phone/Fax

Practice location:
  • Phone: 412-322-4151
  • Fax: 844-389-1405
Mailing address:
  • Phone: 412-322-4151
  • Fax: 844-389-1405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP017175
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: