MEDICARE: MR. GREGORY ROBERT OBRAY PA-C

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	363AS0400X	Surgical Physician Assistant	00034506	WA
2	363AS0400X	Surgical Physician Assistant	M7482	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083770192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGORY ROBERT OBRAY PA-C

Provider Business Mailing Address
First Line	:	PO BOX 189
Second Line	:
City	:	CLARKSTON
State	:	WA
Zip	:	99403-0189
Country	:	US
Telephone Number	:	509-758-2254
Fax Number	:	509-758-2255

Provider Business Practice Location Address
First Line	:	1207 EVERGREEN CT
Second Line	:
City	:	CLARKSTON
State	:	WA
Zip	:	99403-2874
Country	:	US
Telephone Number	:	509-769-2254
Fax Number	:	509-769-2255

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

Provider Enumeration Date	:	12/31/2006
Last Update Date	:	01/21/2026

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