Healthcare Provider Details

I. General information

NPI: 1083770192
Provider Name (Legal Business Name): GREGORY ROBERT OBRAY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2006
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 EVERGREEN CT
CLARKSTON WA
99403-2874
US

IV. Provider business mailing address

320 WARNER DR
LEWISTON ID
83501-4441
US

V. Phone/Fax

Practice location:
  • Phone: 509-769-2254
  • Fax: 509-751-9406
Mailing address:
  • Phone: 208-743-3523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number00034506
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberM7482
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: