Healthcare Provider Details

I. General information

NPI: 1609966993
Provider Name (Legal Business Name): SHANTELL S WRAY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2006
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1296 W BROAD ST
GROVELAND FL
34736-2012
US

IV. Provider business mailing address

110 S WOODLAND ST
WINTER GARDEN FL
34787-3546
US

V. Phone/Fax

Practice location:
  • Phone: 407-905-8827
  • Fax: 352-429-5606
Mailing address:
  • Phone: 407-905-8827
  • Fax: 407-905-8998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number002435
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: