Provider Demographics
NPI:1497710776
Name:RABALAIS, GREGORY (CRNA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:RABALAIS
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 1:400 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:952-442-3620
Practice Address - Street 1:1015 UNITY RD
Practice Address - Street 2:HWY 82E
Practice Address - City:CROSSETT
Practice Address - State:AR
Practice Address - Zip Code:71635-9443
Practice Address - Country:US
Practice Address - Phone:870-364-1280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR63088367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136838701Medicaid
AR5U361OtherBLUE CROSS OF AR
AR5U361C503Medicare ID - Type Unspecified
AR430053739Medicare ID - Type UnspecifiedRAILROAD MEDICARE