Provider Demographics
NPI:1033192042
Name:HAUSER, LEEANA G (MD)
Entity Type:Individual
Prefix:
First Name:LEEANA
Middle Name:G
Last Name:HAUSER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SNAKE
Other - Middle Name:RIVER
Other - Last Name:PATHOLOGY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1321 OAKLEY AVE #2
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-0001
Mailing Address - Country:US
Mailing Address - Phone:208-678-3063
Mailing Address - Fax:
Practice Address - Street 1:1321 OAKLEY AVE #2
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-0001
Practice Address - Country:US
Practice Address - Phone:208-678-3063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7101207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1400655Medicare PIN