Provider Demographics
NPI:1740361815
Name:GAMMILL, BRADLEY G (CRNA)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:G
Last Name:GAMMILL
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 1:795 EASTERN BYP
Mailing Address - Street 2:BUILDING 2, SUITE 6
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2406
Mailing Address - Country:US
Mailing Address - Phone:859-624-1879
Mailing Address - Fax:859-625-3171
Practice Address - Street 1:PATTIE A CLAY HOSPITAL
Practice Address - Street 2:801 EASTERN BYPASS
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475
Practice Address - Country:US
Practice Address - Phone:859-624-1879
Practice Address - Fax:859-625-3171
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1090024367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74002239Medicaid
KY3395120Medicare ID - Type UnspecifiedGROUP 0143
KYR98517Medicare UPIN
KY74002239Medicaid