Healthcare Provider Details

I. General information

NPI: 1417640301
Provider Name (Legal Business Name): LILY WRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 05/29/2023
Certification Date: 05/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 GALISTEO ST
SANTA FE NM
87505-4747
US

IV. Provider business mailing address

9600 SW 175TH AVE
BEAVERTON OR
97007-9726
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-8313
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: