MEDICARE: MRS. LEATRICE R COWAN CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	A810086	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346294550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LEATRICE R COWAN CRNA

Provider Business Mailing Address
First Line	:	1760 BENNING ST
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38106-6231
Country	:	US
Telephone Number	:	901-948-1033
Fax Number	:	662-621-5087

Provider Business Practice Location Address
First Line	:	1970 HOSPITAL DR
Second Line	:
City	:	CLARKSDALE
State	:	MS
Zip	:	38614-7202
Country	:	US
Telephone Number	:	662-624-3534
Fax Number	:	662-621-5087

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	06/27/2013

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