1700954070 NPI number — RANDY R GRAY CRNA

Table of content: RANDY R GRAY CRNA (NPI 1700954070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700954070 NPI number — RANDY R GRAY CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
RANDY
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700954070
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6940
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95927-6940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-518-9290
Provider Business Mailing Address Fax Number:
530-899-1953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2550 SISTER MARY COLUMBA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RED BLUFF
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96080-4327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-528-8701
Provider Business Practice Location Address Fax Number:
530-528-8712
Provider Enumeration Date:
12/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  258 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NA258 . This is a "CERTIFIED NURSE ANETHETIS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1700954070 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".