1871573014 NPI number — MARK S LEATH CRNA

Table of content: MARK S LEATH CRNA (NPI 1871573014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871573014 NPI number — MARK S LEATH CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEATH
Provider First Name:
MARK
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871573014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3185
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71210-3185
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-998-6129
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4864 JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71202-6400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-330-7626
Provider Business Practice Location Address Fax Number:
318-330-7648
Provider Enumeration Date:
01/21/2006

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: 367500000X , with the licence number:  AP05050 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: C01511 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1454222 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 157491001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5Y301 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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