Basic Information
| Provider Information | |||||||||
| NPI: | 1215946587 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEAF | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 732 SUMMITVIEW AVE | ||||||||
| Address2: | #633 | ||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989023032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095733448 | ||||||||
| FaxNumber: | 5095744481 | ||||||||
| Practice Location | |||||||||
| Address1: | 502 W 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989481616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098653105 | ||||||||
| FaxNumber: | 5095744481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 01/09/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AP30005070 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 9604489 | 05 | WA | MEDICAID |