Healthcare Provider Details

I. General information

NPI: 1245635291
Provider Name (Legal Business Name): AMANDA MALONE GRAY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS AMANDA NICOLE MALONE

II. Dates (important events)

Enumeration Date: 11/01/2014
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 WOLF PARK DR STE 102
GERMANTOWN TN
38138-1759
US

IV. Provider business mailing address

1325 WOLF PARK DR STE 103
GERMANTOWN TN
38138-1759
US

V. Phone/Fax

Practice location:
  • Phone: 901-252-3400
  • Fax: 901-763-4305
Mailing address:
  • Phone: 901-252-3400
  • Fax: 901-763-4305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2676
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2676
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00598
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: