Provider Demographics
NPI:1417915349
Name:WALDRON, GARY L (CRNA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:WALDRON
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 1:328 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9693
Mailing Address - Country:US
Mailing Address - Phone:270-789-3766
Mailing Address - Fax:
Practice Address - Street 1:320 LORETTO RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1300
Practice Address - Country:US
Practice Address - Phone:270-692-3161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1061368367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74280710Medicaid
KY74280710Medicaid