Provider Demographics
NPI:1972560779
Name:LIEB, LARRY D (CRNA ARNP)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:LIEB
Suffix:
Gender:M
Credentials:CRNA ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 W RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-3601
Mailing Address - Country:US
Mailing Address - Phone:712-792-1004
Mailing Address - Fax:712-792-4100
Practice Address - Street 1:1301 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:IA
Practice Address - Zip Code:51449-1585
Practice Address - Country:US
Practice Address - Phone:712-464-3171
Practice Address - Fax:712-464-7412
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD-059739363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA5200063OtherCSA
IAD-059739OtherCRNA LICENSE
IAD-059739OtherCRNA LICENSE