Provider Demographics
NPI:1922440361
Name:GRAY, STEPHANIE M (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:GRAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:M
Other - Last Name:WITBRODT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 GOODALL DR
Mailing Address - Street 2:
Mailing Address - City:EAST WATERBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04030-5214
Mailing Address - Country:US
Mailing Address - Phone:207-490-7760
Mailing Address - Fax:
Practice Address - Street 1:10 GOODALL DR
Practice Address - Street 2:
Practice Address - City:EAST WATERBORO
Practice Address - State:ME
Practice Address - Zip Code:04030-5214
Practice Address - Country:US
Practice Address - Phone:207-490-7760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-26
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1092363A00000X
MEPA1416363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3102665Medicaid