Healthcare Provider Details

I. General information

NPI: 1639568314
Provider Name (Legal Business Name): TINA A LEASURE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TINA RAMESHBHAI

II. Dates (important events)

Enumeration Date: 01/17/2015
Last Update Date: 08/01/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL DRIVE
BORGER TX
79007-7579
US

IV. Provider business mailing address

443 OLD PECK HILL RD
GLOVERSVILLE NY
12078-6633
US

V. Phone/Fax

Practice location:
  • Phone: 806-467-5700
  • Fax:
Mailing address:
  • Phone: 512-466-1223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number246966
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number695188
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9176
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number106240
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number106240
License Number StateWI
# 6
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD158230
License Number StateIA
# 7
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number695188
License Number StateNY
# 8
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1003336
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: