Healthcare Provider Details

I. General information

NPI: 1174929095
Provider Name (Legal Business Name): CARLY JEAN GRAY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARLY J SMITH PA

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 CARATOKE HWY
MOYOCK NC
27958-8740
US

IV. Provider business mailing address

PO BOX 11314
BELFAST ME
04915-4004
US

V. Phone/Fax

Practice location:
  • Phone: 252-435-6621
  • Fax: 252-435-2685
Mailing address:
  • Phone: 757-842-4481
  • Fax: 757-312-3135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110004737
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-06904
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: