MEDICARE: OLIVIA LEE GRAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	2530	WV

General Provider Information

NPI Number	:	1073117685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA LEE GRAY

Provider Business Mailing Address
First Line	:	1006 COMMERCE ST
Second Line	:
City	:	WELLSBURG
State	:	WV
Zip	:	26070-1567
Country	:	US
Telephone Number	:	304-737-4435
Fax Number	:

Provider Business Practice Location Address
First Line	:	1006 COMMERCE ST
Second Line	:
City	:	WELLSBURG
State	:	WV
Zip	:	26070-1567
Country	:	US
Telephone Number	:	304-737-4435
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/24/2020
Last Update Date	:	06/26/2023

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Directions to “ OLIVIA LEE GRAY ” Practice Location

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