Provider Demographics
NPI:1740803303
Name:GRAY, TODD (APRN)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:GRAY
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 AMERICAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5031
Mailing Address - Country:US
Mailing Address - Phone:414-336-8656
Mailing Address - Fax:414-240-1777
Practice Address - Street 1:725 AMERICAN AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5031
Practice Address - Country:US
Practice Address - Phone:414-336-8656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15708363LA2100X, 363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1740803303Medicaid
WI239392OtherNURSES LICENSE