Individual
MARK S LEATH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
4864 JACKSON ST, MONROE, LA 71202-6400
(318) 330-7626
(318) 330-7648
Mailing address
PO BOX 3185, MONROE, LA 71210-3185
(318) 998-6129
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
AP05050
LA
367500000X
Certified Registered Nurse Anesthetist
C01511
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1454222
—
LA
05
—
157491001
—
AR
01
—
5Y301
BCBS
AR
Enumeration date
01/21/2006
Last updated
08/28/2017
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