Provider Demographics
NPI:1043773070
Name:KEPHART, GRANT DAVID (CRNA)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:DAVID
Last Name:KEPHART
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 1:1148 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-4003
Mailing Address - Country:US
Mailing Address - Phone:530-864-8882
Mailing Address - Fax:
Practice Address - Street 1:ST. JOSEPH'S MEDICAL CENTER
Practice Address - Street 2:1800 N. CALIFORNIA ST.
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204
Practice Address - Country:US
Practice Address - Phone:209-943-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA95001045367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered