Provider Demographics
NPI:1902974991
Name:NIELSEN, LEON R (CRNA)
Entity type:Individual
Prefix:MR
First Name:LEON
Middle Name:R
Last Name:NIELSEN
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 1:810 BEAVER DR
Mailing Address - Street 2:
Mailing Address - City:GOODLAND
Mailing Address - State:KS
Mailing Address - Zip Code:67735-9781
Mailing Address - Country:US
Mailing Address - Phone:785-899-6368
Mailing Address - Fax:
Practice Address - Street 1:220 W 2ND ST
Practice Address - Street 2:
Practice Address - City:GOODLAND
Practice Address - State:KS
Practice Address - Zip Code:67735-1602
Practice Address - Country:US
Practice Address - Phone:785-890-3625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54087367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS12116OtherBLUE SHIELD #
KS100246240AOtherMEDICIAID PROVIDER #