Provider Demographics
NPI:1619991973
Name:LEFOR, GLENN (CRNA)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:LEFOR
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:GLENN
Other - Middle Name:
Other - Last Name:LEFOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:30 7TH ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4335
Mailing Address - Country:US
Mailing Address - Phone:701-456-4000
Mailing Address - Fax:701-456-4800
Practice Address - Street 1:30 7TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4335
Practice Address - Country:US
Practice Address - Phone:701-456-4000
Practice Address - Fax:701-456-4800
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR31505367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered