Provider Demographics
NPI:1245635291
Name:GRAY, AMANDA MALONE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MALONE
Last Name:GRAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:NICOLE
Other - Last Name:MALONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1325 WOLF PARK DR STE 103
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1759
Mailing Address - Country:US
Mailing Address - Phone:901-252-3400
Mailing Address - Fax:901-763-4305
Practice Address - Street 1:1325 WOLF PARK DR STE 102
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1759
Practice Address - Country:US
Practice Address - Phone:901-252-3400
Practice Address - Fax:901-763-4305
Is Sole Proprietor?:No
Enumeration Date:2014-11-01
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2676363AS0400X, 363A00000X
MSPA00598363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical