Provider Demographics
NPI:1376975037
Name:MCKINNEY, GREGORY JAMES (CRNA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JAMES
Last Name:MCKINNEY
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 1:625 E BROADWAY AVE BOX 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-739-7218
Mailing Address - Fax:307-739-7446
Practice Address - Street 1:625 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8642
Practice Address - Country:US
Practice Address - Phone:307-739-7218
Practice Address - Fax:307-739-7446
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY41799.1797367500000X, 367500000X
TNAPN17871367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY150883100Medicaid