Provider Demographics
NPI:1457379463
Name:GRAY, FLETE WARREN (PA)
Entity Type:Individual
Prefix:
First Name:FLETE
Middle Name:WARREN
Last Name:GRAY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4925
Mailing Address - Country:US
Mailing Address - Phone:651-968-5050
Mailing Address - Fax:651-968-5900
Practice Address - Street 1:1600 SAINT JOHNS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1190
Practice Address - Country:US
Practice Address - Phone:651-968-5200
Practice Address - Fax:651-968-5903
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8833363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP96863Medicare UPIN