Provider Demographics
NPI:1316609902
Name:LEBLANC, JAY STEPHEN (CRNA)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:STEPHEN
Last Name:LEBLANC
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 47159
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-0159
Mailing Address - Country:US
Mailing Address - Phone:765-559-3779
Mailing Address - Fax:763-450-3986
Practice Address - Street 1:14700 28TH AVE N STE 20
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-4876
Practice Address - Country:US
Practice Address - Phone:765-559-3779
Practice Address - Fax:763-450-3986
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT12812621-4406367500000X
MN2663367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered