Basic Information
| Provider Information | |||||||||
| NPI: | 1093882763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRISHAM | ||||||||
| FirstName: | DEAN | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 CAISSON HILL RD | ||||||||
| Address2: | |||||||||
| City: | FORT RILEY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 664427037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852407678 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 CAISSON HILL RD | ||||||||
| Address2: | |||||||||
| City: | FORT RILEY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 664427037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852407678 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 04/27/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0001197573 | VA | N | Nursing Service Providers | Registered Nurse | 367500000X | 0024169253 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 557052 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 14117177012 | KS | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 200743350A | 05 | KS | MEDICAID |