Provider Demographics
NPI:1912158320
Name:GRAY, AMANDA (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
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 1:401 BURRO ALY
Mailing Address - Street 2:PO BOX 218
Mailing Address - City:MORENCI
Mailing Address - State:AZ
Mailing Address - Zip Code:85540-9647
Mailing Address - Country:US
Mailing Address - Phone:928-865-9184
Mailing Address - Fax:928-865-7571
Practice Address - Street 1:401 BURRO ALY
Practice Address - Street 2:
Practice Address - City:MORENCI
Practice Address - State:AZ
Practice Address - Zip Code:85540-9647
Practice Address - Country:US
Practice Address - Phone:928-865-9184
Practice Address - Fax:928-865-7571
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-03
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104721363A00000X
NMPA2009-0040363A00000X
AZ5389363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM302943Medicare PIN