MEDICARE: CHRISTINA GRAY ATC

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	2255A2300X	Athletic Trainer	AT-AT-1006143	OR

General Provider Information

NPI Number	:	1881657138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA GRAY ATC

Provider Business Mailing Address
First Line	:	5484 SE ROETHE RD
Second Line	:
City	:	MILWAUKIE
State	:	OR
Zip	:	97267-5054
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	765 14TH ST NE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-2611
Country	:	US
Telephone Number	:	503-504-5686
Fax Number	:

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

Provider Enumeration Date	:	04/08/2006
Last Update Date	:	07/08/2007

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