Provider Demographics
NPI:1851337984
Name:SNYDER, GRADY KING JR (MD)
Entity Type:Individual
Prefix:
First Name:GRADY
Middle Name:KING
Last Name:SNYDER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3443 ALPINE DR
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-5917
Mailing Address - Country:US
Mailing Address - Phone:307-441-1026
Mailing Address - Fax:
Practice Address - Street 1:3443 ALPINE DR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-5917
Practice Address - Country:US
Practice Address - Phone:307-441-1026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27626207Q00000X
WY9504A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00942266OtherRR MEDICARE
CO01276260Medicaid
CO01276260Medicaid
COA104265Medicare PIN
COE30237Medicare UPIN