Provider Demographics
NPI:1124558440
Name:GRAY, WESLEY DERRINGER JR
Entity Type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:DERRINGER
Last Name:GRAY
Suffix:JR
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 1:1542 E 74TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-7334
Mailing Address - Country:US
Mailing Address - Phone:918-955-2030
Mailing Address - Fax:
Practice Address - Street 1:1542 E 74TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-7334
Practice Address - Country:US
Practice Address - Phone:918-955-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator