Provider Demographics
NPI:1790440170
Name:GRAY, ROBERT LANCE
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LANCE
Last Name:GRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3426 DEWBERRY LN
Mailing Address - Street 2:
Mailing Address - City:MACEDON
Mailing Address - State:NY
Mailing Address - Zip Code:14502-8725
Mailing Address - Country:US
Mailing Address - Phone:585-208-5986
Mailing Address - Fax:
Practice Address - Street 1:3426 DEWBERRY LN
Practice Address - Street 2:
Practice Address - City:MACEDON
Practice Address - State:NY
Practice Address - Zip Code:14502-8725
Practice Address - Country:US
Practice Address - Phone:585-208-5986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305340373344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi