Healthcare Provider Details

I. General information

NPI: 1144285065
Provider Name (Legal Business Name): CHRISTOPHER LEON GRAY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LANG AVE NE SUITE 100
ALBUQUERQUE NM
87109-4495
US

IV. Provider business mailing address

9677 EAGLE RANCH RD NW APT 116
ALBUQUERQUE NM
87114-5854
US

V. Phone/Fax

Practice location:
  • Phone: 505-883-2574
  • Fax: 505-265-4033
Mailing address:
  • Phone: 575-521-9246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2005-0025
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: