Provider Demographics
NPI:1619991791
Name:GRADY, WILLIAM T JR (CRNA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:T
Last Name:GRADY
Suffix:JR
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:PO BOX 1057
Mailing Address - Street 2:
Mailing Address - City:OLMITO
Mailing Address - State:TX
Mailing Address - Zip Code:78575-1057
Mailing Address - Country:US
Mailing Address - Phone:956-498-7669
Mailing Address - Fax:956-350-9881
Practice Address - Street 1:1601 SANTA ANA AVE
Practice Address - Street 2:
Practice Address - City:RANCHO VIEJO
Practice Address - State:TX
Practice Address - Zip Code:78575-9760
Practice Address - Country:US
Practice Address - Phone:956-498-7669
Practice Address - Fax:956-350-9881
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX636370367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX002170103Medicaid
TX610201Medicare ID - Type Unspecified
TXS48358Medicare UPIN