Provider Demographics
NPI:1104962216
Name:BRANUM, GARY S (CRNA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:S
Last Name:BRANUM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11225
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-2225
Mailing Address - Country:US
Mailing Address - Phone:423-892-5602
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:975 E THIRD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-778-7806
Practice Address - Fax:423-778-2360
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN65030163W00000X
TNAPN11063367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00252614OtherRAILROAD MEDICARE
GA879916758BMedicaid
TN3601670Medicaid
TN4102567OtherBLUE CROSS BLUE SHIELD TN
AL009932774Medicaid
NC8052303Medicaid
TN3601670Medicaid