Provider Demographics
NPI:1326440439
Name:GRAY, LISA MARIE (DNP)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:GRAY
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 COCHRANE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4613
Mailing Address - Country:US
Mailing Address - Phone:719-526-7061
Mailing Address - Fax:719-526-7132
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4613
Practice Address - Country:US
Practice Address - Phone:719-526-7061
Practice Address - Fax:719-526-7132
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC268905363LF0000X
COC-APN.0000410-C-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1326440439Medicaid
NC1326440439Medicaid
NCNCL174FMedicare PIN
NCNCL174EMedicare PIN
NCNCL174BMedicare PIN
NCNCL174DMedicare PIN
NCNCL174AMedicare PIN