Provider Demographics
NPI:1811971690
Name:LEGOAS, IVAN (CRNA)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:LEGOAS
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 1:11344 ABBITT TRL
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-0016
Mailing Address - Country:US
Mailing Address - Phone:574-268-9640
Mailing Address - Fax:574-268-0684
Practice Address - Street 1:7150 CLEARVISTA DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1695
Practice Address - Country:US
Practice Address - Phone:317-621-5890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28139740A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2534681Medicaid
000000355824OtherANTHEM BLUE SHIELD
KY74009135Medicaid
IN20019921Medicaid
OH2534681Medicaid
P00246993Medicare PIN