Provider Demographics
NPI:1528233129
Name:GRAY, STACI ANN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:ANN
Last Name:GRAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16811 BURKE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-2253
Mailing Address - Country:US
Mailing Address - Phone:402-573-7337
Mailing Address - Fax:402-614-2314
Practice Address - Street 1:16811 BURKE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-2253
Practice Address - Country:US
Practice Address - Phone:402-573-7337
Practice Address - Fax:402-614-2314
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE652363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant