Basic Information
Provider Information | |||||||||
NPI: | 1326381666 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAY | ||||||||
FirstName: | COURTNEY | ||||||||
MiddleName: | CHRISTINE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 ROUTE 59 | ||||||||
Address2: | SUITE 111 | ||||||||
City: | SUFFERN | ||||||||
State: | NY | ||||||||
PostalCode: | 109014927 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8453575775 | ||||||||
FaxNumber: | 8453575777 | ||||||||
Practice Location | |||||||||
Address1: | 255 LAFAYETTE AVE | ||||||||
Address2: | ANESTHESIA OFFICE | ||||||||
City: | SUFFERN | ||||||||
State: | NY | ||||||||
PostalCode: | 109014812 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8453685039 | ||||||||
FaxNumber: | 8453685327 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/05/2013 | ||||||||
LastUpdateDate: | 08/31/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 629650 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | RN275723 | MA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.