Healthcare Provider Details

I. General information

NPI: 1528037397
Provider Name (Legal Business Name): PETER J GRAY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 DELTA WATERS RD SUITE 107
MEDFORD OR
97504-9114
US

IV. Provider business mailing address

815 N CENTRAL AVE SUITE C
MEDFORD OR
97501-5873
US

V. Phone/Fax

Practice location:
  • Phone: 541-858-2515
  • Fax: 541-858-2514
Mailing address:
  • Phone: 541-734-9030
  • Fax: 541-734-9885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10003890
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA154108
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: