Provider Demographics
NPI:1942594536
Name:GRAY, ANDREW C (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:C
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 1:5544 GREENWICH RD STE 200
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-6563
Mailing Address - Country:US
Mailing Address - Phone:757-466-0089
Mailing Address - Fax:757-466-8017
Practice Address - Street 1:5544 GREENWICH RD STE 200
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-6563
Practice Address - Country:US
Practice Address - Phone:757-466-0089
Practice Address - Fax:757-466-8017
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003602363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10078324POtherOPTIMA
VA428508OtherBCBS OF VA
VAP00953005OtherRAILROAD MEDICARE
VA1942594536Medicaid
VA10078324POtherSENTARA
VAVV2350AMedicare PIN