Healthcare Provider Details

I. General information

NPI: 1861589749
Provider Name (Legal Business Name): MARISSA LEE GRAY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11001 DURANT RD SUITE 100
RALEIGH NC
27614-8390
US

IV. Provider business mailing address

11001 DURANT RD SUITE 100
RALEIGH NC
27614-8390
US

V. Phone/Fax

Practice location:
  • Phone: 919-781-2500
  • Fax: 919-781-9247
Mailing address:
  • Phone: 919-781-2500
  • Fax: 919-781-9247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number103621
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: