Provider Demographics
NPI:1346493970
Name:WRAY, KATHRYN MICHELE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:MICHELE
Last Name:WRAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KATHRYN
Other - Middle Name:MICHELE
Other - Last Name:STANLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:24 OSPREY RD
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3684
Mailing Address - Country:US
Mailing Address - Phone:928-279-8010
Mailing Address - Fax:
Practice Address - Street 1:200 VETERANS AVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6444
Practice Address - Country:US
Practice Address - Phone:304-255-2121
Practice Address - Fax:304-256-5483
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
AZ4379363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ414740Medicaid