Provider Demographics
NPI:1518497528
Name:GRAY, SAMANTHA PAIGE (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:PAIGE
Last Name:GRAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2419 W BRIDLEWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-6025
Mailing Address - Country:US
Mailing Address - Phone:417-830-9553
Mailing Address - Fax:
Practice Address - Street 1:1965 S FREMONT AVE STE 230
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2258
Practice Address - Country:US
Practice Address - Phone:417-830-9553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant