Provider Demographics
NPI:1184676900
Name:GRAY, PETER L (CRNA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:L
Last Name:GRAY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10603 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:BARNEVELD
Mailing Address - State:NY
Mailing Address - Zip Code:13304-2909
Mailing Address - Country:US
Mailing Address - Phone:315-896-2214
Mailing Address - Fax:315-896-2214
Practice Address - Street 1:1656 CHAMPLIN AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4830
Practice Address - Country:US
Practice Address - Phone:315-624-3456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY448862367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered