Healthcare Provider Details

I. General information

NPI: 1588095285
Provider Name (Legal Business Name): BRYAN MATTHEW GRAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2013
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 EASTERN AVE
BALTIMORE MD
21224-2772
US

IV. Provider business mailing address

4014 PENNY LN
CHESAPEAKE VA
23322-2010
US

V. Phone/Fax

Practice location:
  • Phone: 410-814-4500
  • Fax:
Mailing address:
  • Phone: 757-636-5978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110004415
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7760-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: