Provider Demographics
NPI:1609966993
Name:WRAY, SHANTELL S (PA)
Entity Type:Individual
Prefix:
First Name:SHANTELL
Middle Name:S
Last Name:WRAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:110 S WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3546
Mailing Address - Country:US
Mailing Address - Phone:407-905-8827
Mailing Address - Fax:407-905-8998
Practice Address - Street 1:1296 W BROAD ST
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:FL
Practice Address - Zip Code:34736-2012
Practice Address - Country:US
Practice Address - Phone:407-905-8827
Practice Address - Fax:352-429-5606
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT002435363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1071883OtherNCCPA
FL115500100Medicaid