Provider Demographics
NPI:1053389296
Name:HART, LEO DANIEL (CRNA)
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:DANIEL
Last Name:HART
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 1:801 13TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLES CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50616-3443
Mailing Address - Country:US
Mailing Address - Phone:641-228-1143
Mailing Address - Fax:641-228-7621
Practice Address - Street 1:801 13TH ST
Practice Address - Street 2:
Practice Address - City:CHARLES CITY
Practice Address - State:IA
Practice Address - Zip Code:50616-3443
Practice Address - Country:US
Practice Address - Phone:641-228-1143
Practice Address - Fax:641-228-7621
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD054447163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0126649Medicaid
IA51738Medicare ID - Type Unspecified