Provider Demographics
NPI:1700954070
Name:GRAY, RANDY R (CRNA)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:R
Last Name:GRAY
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 6940
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95927-6940
Mailing Address - Country:US
Mailing Address - Phone:530-518-9290
Mailing Address - Fax:530-899-1953
Practice Address - Street 1:2550 SISTER MARY COLUMBA DR
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-4327
Practice Address - Country:US
Practice Address - Phone:530-528-8701
Practice Address - Fax:530-528-8712
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA258367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANA258OtherCERTIFIED NURSE ANETHETIS
CA1700954070Medicaid
CA1700954070Medicaid
S11853Medicare UPIN