Provider Demographics
NPI:1336120575
Name:BRAY, CHARLES P (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:P
Last Name:BRAY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5555 GLENWOOD HILLS PKWY SE STE 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2091
Mailing Address - Country:US
Mailing Address - Phone:616-940-2662
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:2680 LEONARD ST NE STE 3
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6901
Practice Address - Country:US
Practice Address - Phone:616-317-7246
Practice Address - Fax:616-920-6540
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001995363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P70026934OtherRAILROAD MEDICARE
P70026934OtherRAILROAD MEDICARE
MIN88490004Medicare PIN