Basic Information
| Provider Information | |||||||||
| NPI: | 1376975037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKINNEY | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 E BROADWAY AVE BOX 428 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830010428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077397218 | ||||||||
| FaxNumber: | 3077397446 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 E BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830018642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077397218 | ||||||||
| FaxNumber: | 3077397446 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2013 | ||||||||
| LastUpdateDate: | 02/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 41799.1797 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 150883100 | 05 | WY | MEDICAID |