Provider Demographics
NPI:1598815102
Name:LEITELT, ROBERT A (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:LEITELT
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 1:1701 LAKE LANSING RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-3798
Mailing Address - Country:US
Mailing Address - Phone:517-485-0001
Mailing Address - Fax:517-485-1138
Practice Address - Street 1:1 N ATKINSON DR
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1906
Practice Address - Country:US
Practice Address - Phone:231-845-2348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRL075659367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4319992Medicaid