Provider Demographics
NPI:1043087869
Name:GRAY, TYLER ANDREW (CPO)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:ANDREW
Last Name:GRAY
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 BOOTH RD
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:VA
Mailing Address - Zip Code:24101-5104
Mailing Address - Country:US
Mailing Address - Phone:540-314-1689
Mailing Address - Fax:
Practice Address - Street 1:445 COMMONWEALTH BLVD E
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-2086
Practice Address - Country:US
Practice Address - Phone:276-634-5690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACPO04879224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist