Provider Demographics
NPI:1770520967
Name:LEUNG, BOAZ Y (CRNA)
Entity type:Individual
Prefix:
First Name:BOAZ
Middle Name:Y
Last Name:LEUNG
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 1:94 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-9284
Mailing Address - Country:US
Mailing Address - Phone:304-264-8933
Mailing Address - Fax:304-264-8846
Practice Address - Street 1:94 OLD MILL RD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-9284
Practice Address - Country:US
Practice Address - Phone:304-264-8933
Practice Address - Fax:304-264-8846
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC000362367500000X
WV71474367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009996Medicaid
MD410478100Medicaid
MD410478100Medicaid
RI007059433Medicare PIN
MA000113601Medicare PIN
MD163156ZAR5Medicare PIN
MD454MO055Medicare UPIN