Provider Demographics
NPI:1881783298
Name:GANDY, MICHAEL RUSSELL (CRNA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RUSSELL
Last Name:GANDY
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 288
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-0288
Mailing Address - Country:US
Mailing Address - Phone:256-880-6711
Mailing Address - Fax:
Practice Address - Street 1:721 MADISON ST SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4408
Practice Address - Country:US
Practice Address - Phone:256-880-6711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1071312367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered