Provider Demographics
NPI:1609906239
Name:GAMBRELL, PAUL GREGG (CRNA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:GREGG
Last Name:GAMBRELL
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 1:5025 AIRPORT CENTER PKWY BLDG L
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5885
Mailing Address - Country:US
Mailing Address - Phone:704-512-7105
Mailing Address - Fax:
Practice Address - Street 1:706 W KING ST
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-2708
Practice Address - Country:US
Practice Address - Phone:980-487-5405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC145612367500000X
NC53044367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8052822Medicaid
NC2618568AMedicare PIN
NC2618568Medicare PIN