Provider Demographics
NPI:1346215829
Name:LEATHERWOOD, WILLIAM ALEXANDER (CRNA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ALEXANDER
Last Name:LEATHERWOOD
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 1:598 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3357
Mailing Address - Country:US
Mailing Address - Phone:478-633-6706
Mailing Address - Fax:478-633-5384
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:478-633-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN106774367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA430076991OtherMCRB RAILROAD
GA000913866AMedicaid
GA000913866CMedicaid
GA00913866BMedicaid
GA511I430479Medicare PIN
GA000913866CMedicaid
GA000913866AMedicaid