Provider Demographics
NPI:1629048343
Name:RICKABAUGH, GREGG ALAN (CRNA)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:ALAN
Last Name:RICKABAUGH
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:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-0388
Mailing Address - Country:US
Mailing Address - Phone:316-281-3700
Mailing Address - Fax:316-282-4322
Practice Address - Street 1:629 S PLUMMER
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720
Practice Address - Country:US
Practice Address - Phone:620-431-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54095367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered