Provider Demographics
NPI:1790895340
Name:GRAY, ROB (PA-C)
Entity Type:Individual
Prefix:
First Name:ROB
Middle Name:
Last Name:GRAY
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 1:50 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-6012
Mailing Address - Country:US
Mailing Address - Phone:770-957-1887
Mailing Address - Fax:770-957-6864
Practice Address - Street 1:50 KELLY RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6012
Practice Address - Country:US
Practice Address - Phone:770-957-1887
Practice Address - Fax:770-957-6864
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3460363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10033126OtherAMERIGROUP
GA1153770002OtherPEACHSTATE
GA319993OtherWELLCARE
GA1153770002OtherPEACHSTATE
GAP10029Medicare UPIN