Provider Demographics
NPI:1528547791
Name:STRODER, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:STRODER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 PRIVATE ROAD 5860
Mailing Address - Street 2:
Mailing Address - City:YANTIS
Mailing Address - State:TX
Mailing Address - Zip Code:75497-4746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:954 PRIVATE ROAD 5860
Practice Address - Street 2:
Practice Address - City:YANTIS
Practice Address - State:TX
Practice Address - Zip Code:75497-4746
Practice Address - Country:US
Practice Address - Phone:636-515-4810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX343634164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty