Provider Demographics
NPI:1659481869
Name:GRAY, MICHAEL (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 RACE ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-3518
Mailing Address - Country:US
Mailing Address - Phone:408-278-3000
Mailing Address - Fax:
Practice Address - Street 1:625 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-3785
Practice Address - Country:US
Practice Address - Phone:408-871-5260
Practice Address - Fax:408-871-3237
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11821363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA118210Medicaid
CA0PA118210Medicare ID - Type Unspecified
CAR78860Medicare UPIN