Healthcare Provider Details

I. General information

NPI: 1801888367
Provider Name (Legal Business Name): DANA ROBERT GRAY PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 04/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 NW LOVEJOY ST SUITE 315
PORTLAND OR
97210-3033
US

IV. Provider business mailing address

975 SE SANDY BLVD SUITE 200
PORTLAND OR
97214-1308
US

V. Phone/Fax

Practice location:
  • Phone: 503-226-6101
  • Fax: 503-227-3422
Mailing address:
  • Phone: 503-963-2846
  • Fax: 503-963-9505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00255
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA10003194
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: