Provider Demographics
NPI:1528037397
Name:GRAY, PETER J (PA-C)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:GRAY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:815 N CENTRAL AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-5873
Mailing Address - Country:US
Mailing Address - Phone:541-734-9030
Mailing Address - Fax:541-734-9885
Practice Address - Street 1:1600 DELTA WATERS RD
Practice Address - Street 2:SUITE 107
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9114
Practice Address - Country:US
Practice Address - Phone:541-858-2515
Practice Address - Fax:541-858-2514
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAPA10003890363A00000X
ORPA154108363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8387318Medicaid
IDKQ548OtherBLUE CROSS OF IDAHO
WA379109600OtherOWCP
ID805608100Medicaid
WA970018798OtherRR MEDICARE
ID000010029019OtherREGENCE BLUE SHIELD OF ID
WA19132OtherGROUP HEALTH NW
WA2030GROtherASURIS NW HEALTH
WA8940235OtherCRIME VICTIMS
WA149070OtherDEPT OF LABOR & INDUSTRIE
ORPA154108OtherMEDICAL LICENSE
MT4310129Medicaid
MT4310129Medicaid
WA970018798OtherRR MEDICARE
MT4310129Medicaid
WA8387318Medicaid