Provider Demographics
NPI:1639378532
Name:CAMPBELL, GARY L II (CRNA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:CAMPBELL
Suffix:II
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 1:243 MAPLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-7047
Mailing Address - Country:US
Mailing Address - Phone:321-287-3048
Mailing Address - Fax:
Practice Address - Street 1:243 MAPLE CREEK DR
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-7047
Practice Address - Country:US
Practice Address - Phone:321-287-3048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA212903367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308547300Medicaid
FLG4333OtherBCBS
FLAE6082Medicare PIN