Provider Demographics
NPI:1649395229
Name:GRAY, WILLIAM RICHARD (PA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RICHARD
Last Name:GRAY
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:2500 NESCONSET HWY
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2555
Mailing Address - Country:US
Mailing Address - Phone:631-689-3005
Mailing Address - Fax:631-689-1750
Practice Address - Street 1:24 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8011
Practice Address - Country:US
Practice Address - Phone:631-647-4567
Practice Address - Fax:631-647-4568
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2023-02-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY003709-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1649395229Medicare NSC