Provider Demographics
NPI:1073585758
Name:TAWODA, LEANNE (CRNA)
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:
Last Name:TAWODA
Suffix:
Gender:F
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 3424
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-3424
Mailing Address - Country:US
Mailing Address - Phone:928-537-4709
Mailing Address - Fax:928-537-2466
Practice Address - Street 1:2200 E SHOW LOW LAKE RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7881
Practice Address - Country:US
Practice Address - Phone:928-537-4375
Practice Address - Fax:928-537-2466
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN044839367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ480210Medicaid
S64465Medicare UPIN
AZ480210Medicaid