Provider Demographics
NPI:1629760855
Name:GRAYSON, SHANE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:GRAYSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:WHITE OAK
Mailing Address - State:PA
Mailing Address - Zip Code:15131-1705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34 BENWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-1761
Practice Address - Country:US
Practice Address - Phone:716-986-9199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030442363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty