Provider Demographics
NPI:1629086699
Name:GRADY, PHILIP L (APRN/CRNA)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:L
Last Name:GRADY
Suffix:
Gender:M
Credentials:APRN/CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4145 CASTLE GATE DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32571-7352
Mailing Address - Country:US
Mailing Address - Phone:850-304-3389
Mailing Address - Fax:
Practice Address - Street 1:6000 W HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32512-0001
Practice Address - Country:US
Practice Address - Phone:850-304-3389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9187026163W00000X
FLARPN9187026367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse