Provider Demographics
NPI:1215904123
Name:MARVIN, LESLIE B (CRNA)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:B
Last Name:MARVIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:B
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 411895
Mailing Address - Street 2:DEPT. 109
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-1895
Mailing Address - Country:US
Mailing Address - Phone:913-632-2230
Mailing Address - Fax:913-789-3191
Practice Address - Street 1:9100 W 74TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-4004
Practice Address - Country:US
Practice Address - Phone:913-632-2230
Practice Address - Fax:913-789-3191
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1488610052163W00000X
KS55062367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO918395302Medicaid
KS100418420BMedicaid
KS430072326OtherRR MEDICARE
MO918395302Medicaid