Provider Demographics
NPI:1235765124
Name:GRAY, PAUL CANNIFF
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:CANNIFF
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 1:219 BERRY RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3190
Mailing Address - Country:US
Mailing Address - Phone:757-338-0353
Mailing Address - Fax:
Practice Address - Street 1:219 BERRY RIDGE LN
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3190
Practice Address - Country:US
Practice Address - Phone:757-338-0353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60621503172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver