Provider Demographics
NPI:1003504929
Name:GRAY, JOSHUA
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 MEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:ME
Mailing Address - Zip Code:04453-5214
Mailing Address - Country:US
Mailing Address - Phone:207-943-6872
Mailing Address - Fax:
Practice Address - Street 1:758 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3224
Practice Address - Country:US
Practice Address - Phone:207-941-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT5951261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy