Healthcare Provider Details

I. General information

NPI: 1669924015
Provider Name (Legal Business Name): GRAYSON THOMAS SANDY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST
MACON GA
31201-2102
US

IV. Provider business mailing address

PO BOX 945375
ATLANTA GA
30394-5375
US

V. Phone/Fax

Practice location:
  • Phone: 516-945-3000
  • Fax: 704-248-5537
Mailing address:
  • Phone: 516-945-3000
  • Fax: 704-248-5553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1129501
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number22654
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN214138
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: