Provider Demographics
NPI:1982350435
Name:RUSSELL-GRAY, ASHLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:RUSSELL-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 1:712 LITTLE BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-3069
Mailing Address - Country:US
Mailing Address - Phone:215-859-8141
Mailing Address - Fax:
Practice Address - Street 1:116 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-7604
Practice Address - Country:US
Practice Address - Phone:910-488-0157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12032363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant