Basic Information
Provider Information | |||||||||
NPI: | 1437103249 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GAITHER | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1020 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | BEAVER DAM | ||||||||
State: | KY | ||||||||
PostalCode: | 423201553 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2702740480 | ||||||||
FaxNumber: | 2702740482 | ||||||||
Practice Location | |||||||||
Address1: | 815 E PARRISH AVE | ||||||||
Address2: | SUITE 460 | ||||||||
City: | OWENSBORO | ||||||||
State: | KY | ||||||||
PostalCode: | 423033222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2706845005 | ||||||||
FaxNumber: | 2709264432 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2006 | ||||||||
LastUpdateDate: | 07/26/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 3966A | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 74005877 | 05 | KY |   | MEDICAID |