Provider Demographics
NPI:1194273540
Name:GRANT, CHARLES (CRNA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:GRANT
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 1:2221 ELM ST
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-5108
Mailing Address - Country:US
Mailing Address - Phone:307-324-2221
Mailing Address - Fax:
Practice Address - Street 1:1000 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9261
Practice Address - Country:US
Practice Address - Phone:217-258-2525
Practice Address - Fax:217-258-4175
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28240666A367500000X
WY42034.1850367500000X
IL209-014807367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered