Provider Demographics
NPI:1952539926
Name:GRAY, LAURA ROSE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ROSE
Last Name:GRAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:LAURA
Other - Middle Name:ROSE
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6839 S CANTON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3402
Mailing Address - Country:US
Mailing Address - Phone:918-494-0612
Mailing Address - Fax:918-481-5170
Practice Address - Street 1:6839 S CANTON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3402
Practice Address - Country:US
Practice Address - Phone:918-494-0612
Practice Address - Fax:918-481-5170
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant