Provider Demographics
NPI:1518698067
Name:GRAY, BRYAN JOSEPH (BSN, RN)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:JOSEPH
Last Name:GRAY
Suffix:
Gender:M
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-2534
Mailing Address - Country:US
Mailing Address - Phone:573-681-3750
Mailing Address - Fax:
Practice Address - Street 1:1001 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2534
Practice Address - Country:US
Practice Address - Phone:573-681-3750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015024072163WH1000X, 163WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0200XNursing Service ProvidersRegistered NurseOncology
Yes163WH1000XNursing Service ProvidersRegistered NurseHospice