Provider Demographics
NPI:1528152287
Name:GRADBERG, SCOTT LEE (CRNA)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:LEE
Last Name:GRADBERG
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 1:135 S GIBSON ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1622
Mailing Address - Country:US
Mailing Address - Phone:715-748-8100
Mailing Address - Fax:715-748-8199
Practice Address - Street 1:135 SOUTH GIBSON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1622
Practice Address - Country:US
Practice Address - Phone:715-748-8100
Practice Address - Fax:715-748-8199
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI047894367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered