Provider Demographics
NPI:1871573014
Name:LEATH, MARK S (CRNA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:LEATH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3185
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71210-3185
Mailing Address - Country:US
Mailing Address - Phone:318-998-6129
Mailing Address - Fax:
Practice Address - Street 1:4864 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-6400
Practice Address - Country:US
Practice Address - Phone:318-330-7626
Practice Address - Fax:318-330-7648
Is Sole Proprietor?:No
Enumeration Date:2006-01-21
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05050367500000X
ARC01511367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1454222Medicaid
AR157491001Medicaid
AR5Y301OtherBCBS
LA1454222Medicaid
LA3A028CM62Medicare PIN
LA3A028Medicare PIN