Basic Information
| Provider Information | |||||||||
| NPI: | 1467444174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIDER | ||||||||
| FirstName: | JAMIE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3320 TATES CREEK RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405023400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592681030 | ||||||||
| FaxNumber: | 8592694120 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 HARDIN LN | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425033818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066783288 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 3359A | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 74005554 | 05 | KY | MEDICAID |