Healthcare Provider Details

I. General information

NPI: 1023215670
Provider Name (Legal Business Name): KERIANN NICKOLA GRAY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SCENERY DR.
STATE COLLEGE PA
16801-5602
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 814-231-4560
  • Fax: 814-231-6246
Mailing address:
  • Phone: 518-525-5634
  • Fax: 518-649-4094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD456589
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number246232
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier464500
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerMEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: