Healthcare Provider Details

I. General information

NPI: 1295384204
Provider Name (Legal Business Name): JESSE MARIE GRAY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 SW 43RD ST STE 140
RENTON WA
98057-4803
US

IV. Provider business mailing address

1412 SW 43RD ST STE 140
RENTON WA
98057-4803
US

V. Phone/Fax

Practice location:
  • Phone: 949-690-5830
  • Fax:
Mailing address:
  • Phone: 949-690-5830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA61117627
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: