Provider Demographics
NPI:1316219231
Name:GATHERAL, CHRISTOPHER (CRNA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:GATHERAL
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 1:2021 KINGSLEY AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5174
Mailing Address - Country:US
Mailing Address - Phone:904-276-5400
Mailing Address - Fax:904-276-5430
Practice Address - Street 1:2021 KINGSLEY AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5174
Practice Address - Country:US
Practice Address - Phone:904-276-5400
Practice Address - Fax:904-276-5430
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9226246367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004773300Medicaid
FLFW311WMedicare PIN