Provider Demographics
NPI:1295772069
Name:GRAY, PAMELA A (MN, FNP)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:A
Last Name:GRAY
Suffix:
Gender:F
Credentials:MN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 N BELAIR RD
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3188
Mailing Address - Country:US
Mailing Address - Phone:706-774-7400
Mailing Address - Fax:706-774-7590
Practice Address - Street 1:465 N BELAIR RD
Practice Address - Street 2:SUITE 2B
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3188
Practice Address - Country:US
Practice Address - Phone:706-774-7400
Practice Address - Fax:706-774-7590
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN094164363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000895947BMedicaid
GA000895947BMedicaid
GAQ21200Medicare UPIN