Healthcare Provider Details

I. General information

NPI: 1639378532
Provider Name (Legal Business Name): GARY L CAMPBELL II CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 MAPLE CREEK DR
NEWNAN GA
30263-7047
US

IV. Provider business mailing address

243 MAPLE CREEK DR
NEWNAN GA
30263-7047
US

V. Phone/Fax

Practice location:
  • Phone: 321-287-3048
  • Fax:
Mailing address:
  • Phone: 321-287-3048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number212903
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: