Provider Demographics
NPI:1255746293
Name:GRAY, JOVAN
Entity type:Individual
Prefix:
First Name:JOVAN
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3455 W CRAIG RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-5118
Mailing Address - Country:US
Mailing Address - Phone:702-776-7772
Mailing Address - Fax:
Practice Address - Street 1:3455 W CRAIG RD
Practice Address - Street 2:SUITE B
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-5118
Practice Address - Country:US
Practice Address - Phone:702-776-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-28
Last Update Date:2014-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1811325095Medicaid