1528037397 NPI number — PETER J GRAY PA-C

Table of content: DR. ARIANA LERMA DO (NPI 1477284214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528037397 NPI number — PETER J GRAY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
PETER
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528037397
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
815 N CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97501-5873
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-734-9030
Provider Business Mailing Address Fax Number:
541-734-9885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 DELTA WATERS RD
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97504-9114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-858-2515
Provider Business Practice Location Address Fax Number:
541-858-2514
Provider Enumeration Date:
03/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA10003890 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA154108 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8387318 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: KQ548 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 379109600 . This is a "OWCP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 805608100 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 970018798 . This is a "RR MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 000010029019 . This is a "REGENCE BLUE SHIELD OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 19132 . This is a "GROUP HEALTH NW" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2030GR . This is a "ASURIS NW HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8940235 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 149070 . This is a "DEPT OF LABOR & INDUSTRIE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: PA154108 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 4310129 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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