Provider Demographics
NPI:1942248125
Name:FITZPATRICK, LEO J (CRNA)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:J
Last Name:FITZPATRICK
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 1:25357 HIGH PASS RD
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97448-9387
Mailing Address - Country:US
Mailing Address - Phone:570-932-1814
Mailing Address - Fax:
Practice Address - Street 1:920 COUNTRY CLUB RD STE 220B
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6090
Practice Address - Country:US
Practice Address - Phone:541-342-5012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN631023367500000X
IL209-05581367500000X
OR201801101CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK22169Medicare UPIN
IL209706Medicare ID - Type Unspecified