Provider Demographics
NPI:1396083192
Name:GRAY, ANDREW T (PA-C)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:T
Last Name:GRAY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8660 BURTON WAY
Mailing Address - Street 2:APT 204
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-3969
Mailing Address - Country:US
Mailing Address - Phone:917-696-8525
Mailing Address - Fax:310-652-2843
Practice Address - Street 1:150 N ROBERTSON BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2142
Practice Address - Country:US
Practice Address - Phone:310-652-2562
Practice Address - Fax:310-652-2843
Is Sole Proprietor?:No
Enumeration Date:2013-01-29
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22797363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA22797OtherMEDICAL LICENSE NUMBER