Provider Demographics
NPI:1417227000
Name:GRAY, CARRIE HORTON (CRNA)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:HORTON
Last Name:GRAY
Suffix:
Gender:F
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:PO BOX 23894
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3894
Mailing Address - Country:US
Mailing Address - Phone:601-376-1848
Mailing Address - Fax:601-376-1894
Practice Address - Street 1:1850 CHADWICK DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3404
Practice Address - Country:US
Practice Address - Phone:601-376-1848
Practice Address - Fax:601-376-1894
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR877355367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04126767Medicaid
MS04126767Medicaid
MS290032YPC0Medicare PIN