Provider Demographics
NPI:1053369157
Name:LEAHY, MARY J (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:LEAHY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 THIELE RD
Mailing Address - Street 2:
Mailing Address - City:YOAKUM
Mailing Address - State:TX
Mailing Address - Zip Code:77995-2130
Mailing Address - Country:US
Mailing Address - Phone:361-550-5549
Mailing Address - Fax:361-741-2354
Practice Address - Street 1:1200 CARL RAMERT DR
Practice Address - Street 2:
Practice Address - City:YOAKUM
Practice Address - State:TX
Practice Address - Zip Code:77995-4868
Practice Address - Country:US
Practice Address - Phone:361-293-2321
Practice Address - Fax:361-293-6172
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX538626367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83648UOtherBCBSTX
TX132831209Medicaid
TX132831215Medicaid
8311UCOtherBCBS TX
TXB145605Medicare PIN
TX8B3468Medicare PIN