Provider Demographics
NPI:1720022296
Name:LANTZ, LEO J (CRNA)
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:J
Last Name:LANTZ
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 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8078
Practice Address - Street 1:3000 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6132
Practice Address - Country:US
Practice Address - Phone:701-364-8000
Practice Address - Fax:701-364-8078
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR24550367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND142339OtherUCARE #
NDDA9011015555OtherPREF 1
NDHP38625OtherHEALTHPARTNERS #
ND2000789OtherMEDICA INNOVIS #
ND38T21LAOtherMNBS #
ND2000790OtherMEDICA FARGO #
ND3881OtherNDBS #
ND029018100Medicaid
ND12655Medicaid
NDHP38625OtherHEALTHPARTNERS #
ND430035669Medicare ID - Type UnspecifiedRAILROAD MEDICARE #
NDDA9011015555OtherPREF 1
ND029018100Medicaid