Provider Demographics
NPI:1477820405
Name:GRAY, JENNIFER PATRICIA (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PATRICIA
Last Name:GRAY
Suffix:
Gender:F
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 1:2600 39TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-4379
Mailing Address - Country:US
Mailing Address - Phone:763-581-5500
Mailing Address - Fax:763-581-5501
Practice Address - Street 1:2600 39TH AVE NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55421-4379
Practice Address - Country:US
Practice Address - Phone:763-581-5500
Practice Address - Fax:763-581-5501
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1651363AM0700X
MN11034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical