Provider Demographics
NPI:1578885919
Name:GRAY, NAWANA MIESA (OWNER/GENERAL MANAGE)
Entity Type:Individual
Prefix:
First Name:NAWANA
Middle Name:MIESA
Last Name:GRAY
Suffix:
Gender:F
Credentials:OWNER/GENERAL MANAGE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 55311
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-8811
Mailing Address - Country:US
Mailing Address - Phone:209-594-9951
Mailing Address - Fax:209-956-0443
Practice Address - Street 1:3007 GINKGO CT
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95212-2716
Practice Address - Country:US
Practice Address - Phone:209-594-9951
Practice Address - Fax:209-956-0443
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11-102997343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)