Provider Demographics
NPI:1083887541
Name:GRAY, JONATHAN GARDNER (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:GARDNER
Last Name:GRAY
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 1:11 NEVINS ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3514
Mailing Address - Country:US
Mailing Address - Phone:617-789-2045
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-724-7739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2275363AS0400X
MAPA2275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical