Provider Demographics
NPI:1164556825
Name:GREY, JEFFERSON IRVING (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEFFERSON
Middle Name:IRVING
Last Name:GREY
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 1:8407 AMHERST VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-2474
Mailing Address - Country:US
Mailing Address - Phone:702-616-1563
Mailing Address - Fax:
Practice Address - Street 1:149 N GIBSON RD STE H
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-6763
Practice Address - Country:US
Practice Address - Phone:702-558-6275
Practice Address - Fax:702-856-3198
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV478363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVBK083BMedicare PIN
NVCJ121ZMedicare PIN
NVBK083AMedicare PIN
NVCJ121YMedicare PIN