Healthcare Provider Details

I. General information

NPI: 1104779636
Provider Name (Legal Business Name): ROBERT MICHAEL GRAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2026
Last Update Date: 02/16/2026
Certification Date: 02/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3332 GREEN RIDGE CT
LAS CRUCES NM
88005-1173
US

IV. Provider business mailing address

3332 GREEN RIDGE CT
LAS CRUCES NM
88005-1173
US

V. Phone/Fax

Practice location:
  • Phone: 575-800-4739
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberG-1967
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: