Healthcare Provider Details

I. General information

NPI: 1700954070
Provider Name (Legal Business Name): RANDY R GRAY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2006
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 SISTER MARY COLUMBA DR
RED BLUFF CA
96080-4327
US

IV. Provider business mailing address

PO BOX 6940
CHICO CA
95927-6940
US

V. Phone/Fax

Practice location:
  • Phone: 530-528-8701
  • Fax: 530-528-8712
Mailing address:
  • Phone: 530-518-9290
  • Fax: 530-899-1953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number258
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: