Provider Demographics
NPI:1205834009
Name:ELMORE, GRADY (NP)
Entity Type:Individual
Prefix:
First Name:GRADY
Middle Name:
Last Name:ELMORE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 TRINITY PL
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30607-2100
Mailing Address - Country:US
Mailing Address - Phone:706-543-2718
Mailing Address - Fax:706-353-3709
Practice Address - Street 1:120 TRINITY PL
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607-2100
Practice Address - Country:US
Practice Address - Phone:706-543-2718
Practice Address - Fax:706-353-3709
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN129091NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00887136AMedicaid
GAP28334Medicare UPIN
GA00887136AMedicaid