Provider Demographics
NPI:1245584978
Name:BRAY, ANDREW MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:MICHAEL
Last Name:BRAY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 26TH ST NW APT 5402
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1926
Mailing Address - Country:US
Mailing Address - Phone:904-327-7543
Mailing Address - Fax:
Practice Address - Street 1:6660 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-3167
Practice Address - Country:US
Practice Address - Phone:404-996-0195
Practice Address - Fax:404-531-0967
Is Sole Proprietor?:No
Enumeration Date:2012-11-02
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106728363A00000X
GA12020363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010588300Medicaid
FLHR841ZMedicare PIN