Healthcare Provider Details

I. General information

NPI: 1902843915
Provider Name (Legal Business Name): PAMELA A. GRAY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: PAMELA A. LISTIAK

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5350 UNIVERSITY PKWY SUITE 201
SARASOTA FL
34243-5812
US

IV. Provider business mailing address

4118 NELSON AVE
SARASOTA FL
34231-8645
US

V. Phone/Fax

Practice location:
  • Phone: 941-917-4500
  • Fax: 941-917-4689
Mailing address:
  • Phone: 239-633-6737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 9101582
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: