Provider Demographics
NPI:1780671628
Name:JETER, LESLIE A (CRNA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:JETER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3155 N POINT PKWY
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT, BUILDING F, SUITE 100
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005
Mailing Address - Country:US
Mailing Address - Phone:770-645-9181
Mailing Address - Fax:770-645-8455
Practice Address - Street 1:2550 WINDY HILL RD SE
Practice Address - Street 2:SUITE 302
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8665
Practice Address - Country:US
Practice Address - Phone:678-574-0943
Practice Address - Fax:678-574-0943
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN081312367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000558346OMedicaid
GA000558346JMedicaid
GA000558346LMedicaid
GA000558346HMedicaid
GA000558346KMedicaid
GA000558346NMedicaid
GA000558346IMedicaid
GA000558346MMedicaid
GA000558346LMedicaid
GA43ZCBXF18Medicare PIN
GA511I430197Medicare PIN
GA000558346IMedicaid