Healthcare Provider Details

I. General information

NPI: 1487046181
Provider Name (Legal Business Name): PAMELA N. GRAY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2015
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 W 10TH ST
ROLLA MO
65401-2905
US

IV. Provider business mailing address

1050 W 10TH ST
ROLLA MO
65401-2905
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-9000
  • Fax: 573-202-2470
Mailing address:
  • Phone: 573-364-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2015006863
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierPENDING
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: