Healthcare Provider Details

I. General information

NPI: 1194273540
Provider Name (Legal Business Name): CHARLES GRANT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HEALTH CENTER DR
MATTOON IL
61938-9261
US

IV. Provider business mailing address

2221 ELM ST
RAWLINS WY
82301-5108
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-2525
  • Fax: 217-258-4175
Mailing address:
  • Phone: 307-324-2221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28240666A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number42034.1850
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209-014807
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: