=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811971690
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IVAN LEGOAS CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2005
-----------------------------------------------------
Last Update Date | 07/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7150 CLEARVISTA DR
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46256-1695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-621-5890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11344 ABBITT TRL
-----------------------------------------------------
City | ZIONSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46077-0016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-268-9640
-----------------------------------------------------
Fax | 574-268-0684
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 28139740A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------