Provider Demographics
NPI:1972866374
Name:GRAY, NATHAN CHARLES (MMS, PA-C)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:CHARLES
Last Name:GRAY
Suffix:
Gender:M
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 DANNY THOMAS PLACE
Mailing Address - Street 2:MS #800
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105
Mailing Address - Country:US
Mailing Address - Phone:901-595-2813
Mailing Address - Fax:901-595-2952
Practice Address - Street 1:262 DANNY THOMAS PLACE
Practice Address - Street 2:MS #800
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105
Practice Address - Country:US
Practice Address - Phone:901-595-2813
Practice Address - Fax:901-595-2952
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03599363A00000X
TN2327363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102662Medicaid
NC8102662Medicaid