Provider Demographics
NPI:1083770192
Name:OBRAY, GREGORY ROBERT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ROBERT
Last Name:OBRAY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 WARNER DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4441
Mailing Address - Country:US
Mailing Address - Phone:208-743-3523
Mailing Address - Fax:
Practice Address - Street 1:320 WARNER DR
Practice Address - Street 2:LEWISTON ORTHOPAEDICS
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-743-3523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00034506363AS0400X
IDM7482363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8204851Medicaid
ID805208800Medicaid
WA8204851Medicaid
WAAB06298Medicare PIN