Provider Demographics
NPI:1043274996
Name:GRACI, CHARLES FREDERICK SR (CRNA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:FREDERICK
Last Name:GRACI
Suffix:SR
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 1:1003 AMICALOLA CT
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-6867
Mailing Address - Country:US
Mailing Address - Phone:770-233-0024
Mailing Address - Fax:
Practice Address - Street 1:1003 AMICALOLA CT
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-6867
Practice Address - Country:US
Practice Address - Phone:770-233-0024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-16
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04381367500000X
GARN212877367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H041Medicare ID - Type UnspecifiedMEDICARE