Provider Demographics
NPI:1033181805
Name:LEACH, KEVIN A (CRNA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:LEACH
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 1:406S 30TH AVE 202
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3713
Mailing Address - Country:US
Mailing Address - Phone:509-972-1051
Mailing Address - Fax:509-972-4166
Practice Address - Street 1:406S 30TH AVE 202
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3713
Practice Address - Country:US
Practice Address - Phone:509-972-1051
Practice Address - Fax:509-972-4166
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR146353-6367500000X
WI160949-030367500000X
WAAP60591499367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN537475800Medicaid
MN537475800Medicaid
OTH000Medicare UPIN