Basic Information
| Provider Information | |||||||||
| NPI: | 1013269307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAUL | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | MARIE COFFMAN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N BEAVER ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860013118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282136235 | ||||||||
| FaxNumber: | 9282136292 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N BEAVER ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860013118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287793366 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2012 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 777690 | CA | N | Nursing Service Providers | Registered Nurse | 163W00000X | 191464 | TN | N | Nursing Service Providers | Registered Nurse | 367500000X | 17352 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | CRNA1509 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 4342775 | 01 | TN | BLUE CROSS TN | OTHER | 196811001 | 05 | AR | MEDICAID | 1013269307 | 01 | TN | CHAMPUS/TRICARE | OTHER | 12528316 | 05 | TN | MEDICAID |