Provider Demographics
NPI:1558409847
Name:MOODY, LESLIE W (CRNA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:W
Last Name:MOODY
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:PO BOX 504944
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4944
Mailing Address - Country:US
Mailing Address - Phone:417-820-4620
Mailing Address - Fax:
Practice Address - Street 1:100 MERCY WAY
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4524
Practice Address - Country:US
Practice Address - Phone:417-556-3570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000166139367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSPENDINGMedicaid
MOPENDINGMedicaid
OKPENDINGMedicaid
MOPENDINGOtherRR MEDICARE
MOPENDINGMedicaid
MOPENDING CARTHAGEMedicare PIN