Provider Demographics
NPI:1346299021
Name:GRAYSON, BYRON KENT (PA)
Entity Type:Individual
Prefix:
First Name:BYRON
Middle Name:KENT
Last Name:GRAYSON
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:PO BOX 6055
Mailing Address - Street 2:
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85376-6055
Mailing Address - Country:US
Mailing Address - Phone:623-977-7211
Mailing Address - Fax:
Practice Address - Street 1:12361 W BOLA DR STE 109
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-9021
Practice Address - Country:US
Practice Address - Phone:623-227-1000
Practice Address - Fax:623-227-2000
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2956363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ841909Medicaid
AZ841909Medicaid
AZQ06958Medicare UPIN