MEDICARE: LARISSA FAITH GRAY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	PA1038	WY
2	363A00000X	Physician Assistant	PA1038	WY

General Provider Information

NPI Number	:	1083344758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARISSA FAITH GRAY PA-C

Provider Business Mailing Address
First Line	:	4227 MINK
Second Line	:
City	:	CASPER
State	:	WY
Zip	:	82604-4509
Country	:	US
Telephone Number	:	307-234-6161
Fax Number	:

Provider Business Practice Location Address
First Line	:	1522 E A ST
Second Line	:
City	:	CASPER
State	:	WY
Zip	:	82601-2254
Country	:	US
Telephone Number	:	307-234-6161
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2022
Last Update Date	:	02/25/2023

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Directions to “ LARISSA FAITH GRAY PA-C” Practice Location

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