Provider Demographics
NPI:1073637708
Name:GRAY, MIKEL (NP)
Entity Type:Individual
Prefix:
First Name:MIKEL
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 RAY C HUNT DR FL 3
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-2981
Practice Address - Country:US
Practice Address - Phone:434-924-2224
Practice Address - Fax:434-982-3652
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024079837208800000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007781555Medicaid
VA500000055Medicare PIN
VAR88330Medicare UPIN