Basic Information
| Provider Information | |||||||||
| NPI: | 1457406894 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANGINAULT | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | JAY | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5865 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794085865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | STE. 1C282 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794308182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432981 | ||||||||
| FaxNumber: | 8067432984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 672045 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 155776101 | 01 | TX | FIRSTCARE COMMERCIAL | OTHER | 155776100 | 05 | TX | MEDICAID | 200103950A | 05 | OK | MEDICAID | 87137U | 01 | TX | HMO BLUE | OTHER | 87136U | 01 | TX | BC BS | OTHER |