Provider Demographics
NPI:1578552188
Name:ROURKE, LEO (ARNP)
Entity Type:Individual
Prefix:MR
First Name:LEO
Middle Name:
Last Name:ROURKE
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9075 SANDIDGE CENTER CV
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-3514
Mailing Address - Country:US
Mailing Address - Phone:662-893-8484
Mailing Address - Fax:662-893-1103
Practice Address - Street 1:9075 SANDIDGE CENTER CV
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-3514
Practice Address - Country:US
Practice Address - Phone:662-893-8484
Practice Address - Fax:662-893-1103
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000006732363LF0000X
MS901896363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3903211OtherFEDERAL MEDICARE NUMBER