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NPI Code Detail

MEDICARE: SHANNON GRAY

MEDICARE: SHANNON GRAY
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
1261QM1300XMulti-Specialty Clinic/Center
2207R00000XInternal Medicine Physician29241AZ

General Provider Information

NPI Number : 1558365536
Entity Type Code : Organization
Provider Name (Legal Business Name) : SHANNON GRAY
Provider Business Mailing Address
First Line : 605 N GILBERT RD
Second Line :
City : MESA
State : AZ
Zip : 85203-6629
Country : US
Telephone Number : 480-398-1220
Fax Number : 480-398-1230
Provider Business Practice Location Address
First Line : 605 N GILBERT RD
Second Line :
City : MESA
State : AZ
Zip : 85203-6629
Country : US
Telephone Number : 480-398-1220
Fax Number : 480-398-1230
Authorized Official
Title or Position : ADMINISTRATOR OWNER
Name : SHANNON GRAY
Credential :
Telephone Number : 480-398-1228
Provider Enumeration Date : 06/08/2005
Last Update Date : 12/29/2017

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Directions to “SHANNON GRAY ” Practice Location

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