MEDICARE: COURTNEY ROSE RAY PA

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	363A00000X	Physician Assistant	2017004542	MO
2	363A00000X	Physician Assistant	4774	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194224949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY ROSE RAY PA

Provider Business Mailing Address
First Line	:	4802 S 109TH EAST AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74146-5822
Country	:	US
Telephone Number	:	918-392-1400
Fax Number	:	918-392-1590

Provider Business Practice Location Address
First Line	:	4812 S 109TH EAST AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74146-5826
Country	:	US
Telephone Number	:	918-392-1400
Fax Number	:

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

Provider Enumeration Date	:	02/07/2018
Last Update Date	:	09/12/2022

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Directions to “ COURTNEY ROSE RAY PA” Practice Location

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