Provider Demographics
NPI:1326067836
Name:LESZCZYNSKI, MARK A (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:LESZCZYNSKI
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 1:1159 OAKTON TRL
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-5224
Mailing Address - Country:US
Mailing Address - Phone:877-727-1960
Mailing Address - Fax:706-854-8454
Practice Address - Street 1:1601 FAIR RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1698
Practice Address - Country:US
Practice Address - Phone:877-727-1960
Practice Address - Fax:706-854-8454
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113930367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA43BBBMDMedicare ID - Type Unspecified