Provider Demographics
NPI:1356742092
Name:GRAY, NATHAN (LMP)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11923 22ND STREET CT E
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98372-1649
Mailing Address - Country:US
Mailing Address - Phone:253-370-7105
Mailing Address - Fax:
Practice Address - Street 1:11923 22ND STREET CT E
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98372-1649
Practice Address - Country:US
Practice Address - Phone:253-370-7105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60497311225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist