Healthcare Provider Details

I. General information

NPI: 1659773463
Provider Name (Legal Business Name): JOSHUA GRAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 MANGO DR
LOUISVILLE KY
40258-2347
US

IV. Provider business mailing address

7600 MANGO DR
LOUISVILLE KY
40258-2347
US

V. Phone/Fax

Practice location:
  • Phone: 502-649-7132
  • Fax:
Mailing address:
  • Phone: 502-649-7132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number1116169
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number3008815
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: