Provider Demographics
NPI:1841520897
Name:GRAY, KYLE JUSTIN (PA)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JUSTIN
Last Name:GRAY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 721776
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-8360
Mailing Address - Country:US
Mailing Address - Phone:405-600-6869
Mailing Address - Fax:405-600-6978
Practice Address - Street 1:11808 S MAY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-2560
Practice Address - Country:US
Practice Address - Phone:405-735-2370
Practice Address - Fax:405-735-2369
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1873363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant