Healthcare Provider Details

I. General information

NPI: 1902290646
Provider Name (Legal Business Name): LESLIE HAVARD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E HIGH ST ANESTHESIA DEPT
POTTSTOWN PA
19464-5008
US

IV. Provider business mailing address

561 MUSKET CT
COLLEGEVILLE PA
19426-1878
US

V. Phone/Fax

Practice location:
  • Phone: 610-487-5116
  • Fax:
Mailing address:
  • Phone: 610-487-5116
  • Fax: 610-409-1952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN600066
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: