Provider Demographics
NPI:1124129374
Name:HUMBRACHT, GREGORY P (CRNA)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:P
Last Name:HUMBRACHT
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 1:2980 SAROSSY LK
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-9455
Mailing Address - Country:US
Mailing Address - Phone:269-251-2117
Mailing Address - Fax:
Practice Address - Street 1:2980 SAROSSY LK
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240-9455
Practice Address - Country:US
Practice Address - Phone:269-251-2117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704115485367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4635722Medicaid
MIZ46025019Medicare ID - Type Unspecified