Provider Demographics
NPI:1225303878
Name:LEISHOLMN, ALONZO CRAIG SR (CHA-IV)
Entity Type:Individual
Prefix:MR
First Name:ALONZO
Middle Name:CRAIG
Last Name:LEISHOLMN
Suffix:SR
Gender:M
Credentials:CHA-IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 385
Mailing Address - Street 2:1036 RAVEN ST
Mailing Address - City:METLAKATLA
Mailing Address - State:AK
Mailing Address - Zip Code:99926-0385
Mailing Address - Country:US
Mailing Address - Phone:907-617-5200
Mailing Address - Fax:907-886-5831
Practice Address - Street 1:563 BRENDIBLE ST
Practice Address - Street 2:
Practice Address - City:METLAKATLA
Practice Address - State:AK
Practice Address - Zip Code:99926-0439
Practice Address - Country:US
Practice Address - Phone:907-886-4741
Practice Address - Fax:907-886-5831
Is Sole Proprietor?:No
Enumeration Date:2012-03-15
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK12-1169-IV172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker