Basic Information
| Provider Information | |||||||||
| NPI: | 1710937198 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KILPATRICK | ||||||||
| FirstName: | GARRY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 MAPLE LN | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 362656852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564355432 | ||||||||
| FaxNumber: | 2564354718 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ANNISTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 362074716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562355860 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 12/01/2009 | ||||||||
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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 | 1-033152 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 51525881 | 01 | AL | BLUE SHIELD | OTHER | 051525881 | 05 | AL | MEDICAID |