Provider Demographics
NPI:1740390384
Name:GRAY, CAROLYN (PA-C)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
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 1:5670 PEACHTREE DUNWOODY RD
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1699
Mailing Address - Country:US
Mailing Address - Phone:404-255-1930
Mailing Address - Fax:404-459-8510
Practice Address - Street 1:5670 PEACHTREE DUNWOODY RD
Practice Address - Street 2:SUITE 1000
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1699
Practice Address - Country:US
Practice Address - Phone:404-255-1930
Practice Address - Fax:404-459-8510
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10033127OtherAMERIGROUP
GA100002586AMedicaid
GA319977OtherWELLCARE
GA1153780002OtherPEACHSTATE
GA970014443OtherRAILROAD MEDICARE
GA100002586AMedicaid
GAP06580Medicare UPIN