=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528037397
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER J GRAY PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 DELTA WATERS RD SUITE 107
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97504-9114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-858-2515
-----------------------------------------------------
Fax | 541-858-2514
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 815 N CENTRAL AVE SUITE C
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97501-5873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-734-9030
-----------------------------------------------------
Fax | 541-734-9885
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA10003890
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA154108
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------