Healthcare Provider Details

I. General information

NPI: 1811990815
Provider Name (Legal Business Name): GARY LEE RAY MSN, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

8105 SLANE CT
CLEMMONS NC
27012-9181
US

V. Phone/Fax

Practice location:
  • Phone: 336-713-2555
  • Fax:
Mailing address:
  • Phone: 336-778-2117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number098705
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number047468
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: