Basic Information
| Provider Information | |||||||||
| NPI: | 1194273540 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | CHARLES | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 ELM ST | ||||||||
| Address2: | |||||||||
| City: | RAWLINS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 823015108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073242221 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 HEALTH CENTER DR | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619389261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172582525 | ||||||||
| FaxNumber: | 2172584175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2016 | ||||||||
| LastUpdateDate: | 01/29/2019 | ||||||||
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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 | 367500000X | 28240666A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 42034.1850 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 209-014807 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.