1215904123 NPI number — LESLIE B MARVIN CRNA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215904123 NPI number — LESLIE B MARVIN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARVIN
Provider First Name:
LESLIE
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BLAKE
Provider Other First Name:
LESLIE
Provider Other Middle Name:
B.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215904123
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8717 W 110TH ST STE 600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66210-2126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-428-2900
Provider Business Mailing Address Fax Number:
913-428-2951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8740 NIEMAN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OVERLAND PARK
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66214-1741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-894-4050
Provider Business Practice Location Address Fax Number:
913-428-2951
Provider Enumeration Date:
03/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  1488610052 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 55062 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 918395302 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100418420B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 430072326 . This is a "RR MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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