Provider Demographics
NPI:1639568314
Name:LEASURE, TINA A (CRNA)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:A
Last Name:LEASURE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:RAMESHBHAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:443 OLD PECK HILL RD
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-6633
Mailing Address - Country:US
Mailing Address - Phone:512-466-1223
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:BORGER
Practice Address - State:TX
Practice Address - Zip Code:79007-7579
Practice Address - Country:US
Practice Address - Phone:806-467-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-17
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI246966163W00000X
NY695188163W00000X, 367500000X
WI9176363L00000X
NY106240367500000X
WI106240367500000X
IAD158230367500000X
TX1003336367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner