Provider Demographics
NPI:1760883151
Name:GRAY, BEAU ASHLEY (CSFA)
Entity Type:Individual
Prefix:MR
First Name:BEAU
Middle Name:ASHLEY
Last Name:GRAY
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 N BOND ST
Mailing Address - Street 2:
Mailing Address - City:IOWA PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76367-1728
Mailing Address - Country:US
Mailing Address - Phone:940-636-2448
Mailing Address - Fax:
Practice Address - Street 1:824 N BOND ST
Practice Address - Street 2:
Practice Address - City:IOWA PARK
Practice Address - State:TX
Practice Address - Zip Code:76367-1728
Practice Address - Country:US
Practice Address - Phone:940-636-2448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX146086246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant