Provider Demographics
NPI:1164063699
Name:GRAY, ISAAC BENJAMIN
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:BENJAMIN
Last Name:GRAY
Suffix:
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 1:2017 W I 35 FRONTAGE RD STE 250
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-8561
Mailing Address - Country:US
Mailing Address - Phone:405-757-3340
Mailing Address - Fax:405-757-3520
Practice Address - Street 1:2017 W I 35 FRONTAGE RD STE 250
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8561
Practice Address - Country:US
Practice Address - Phone:405-757-3340
Practice Address - Fax:405-757-3520
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-06
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK390200000X
OK4544363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program