Provider Demographics
NPI:1417275876
Name:GAYNOR, LESLIE T (CRNA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:T
Last Name:GAYNOR
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARGARET
Other - Middle Name:L
Other - Last Name:GAYNOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:9263 MEDICAL PLAZA DR STE E
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-7112
Mailing Address - Country:US
Mailing Address - Phone:843-572-1228
Mailing Address - Fax:
Practice Address - Street 1:9263 MEDICAL PLAZA DR STE E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-7112
Practice Address - Country:US
Practice Address - Phone:843-572-1228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA042622367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC25890OtherLICENSE
PARN345306LOtherLICENSE