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General NPI Number Information
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NPI Number | 1902952930
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Entity Type | Individual
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Provider Name | ADAM WRAY DO
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Gender | Male
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Dates
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Enumeration Date | 01/25/2007
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Last Update Date | 07/26/2024
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Provider Practice Location Address
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Address Line | 326 POPLAR ST STE 101
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City | BLACKFOOT
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State | ID
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Zip | 83221-1741
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Country | US
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Telephone | 986-275-0003
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Fax | 986-275-0005
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Provider Business Mailing Address
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Address Line | 326 POPLAR ST STE 101
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City | BLACKFOOT
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State | ID
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Zip | 83221-1741
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Country | US
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Telephone | 986-275-0003
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Fax | 986-275-0005
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | O-0444
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License Number State | ID
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