Provider Demographics
NPI:1376630111
Name:MCCARTHY, MONA D (CRNA)
Entity type:Individual
Prefix:
First Name:MONA
Middle Name:D
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MONA
Other - Middle Name:D
Other - Last Name:GRANDSTAFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:327 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9006
Mailing Address - Country:US
Mailing Address - Phone:381-342-1000
Mailing Address - Fax:
Practice Address - Street 1:327 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9006
Practice Address - Country:US
Practice Address - Phone:381-342-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25879367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001722900OtherBCBS
WV0007327000Medicaid
WV205542387OtherAAP TRI CARE NUMBER
WV0836284Medicare PIN
WV001722900OtherBCBS