Provider Demographics
NPI:1831587617
Name:CHAGOLLA, LEON VICTOR II (CRNA)
Entity type:Individual
Prefix:
First Name:LEON
Middle Name:VICTOR
Last Name:CHAGOLLA
Suffix:II
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 1:2751 KINGSFORD DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-4416
Mailing Address - Country:US
Mailing Address - Phone:419-290-6072
Mailing Address - Fax:
Practice Address - Street 1:2751 KINGSFORD DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-4416
Practice Address - Country:US
Practice Address - Phone:419-290-6072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.16947-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered