Basic Information
| Provider Information | |||||||||
| NPI: | 1073873949 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6716 NW 11TH PLACE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523319729 | ||||||||
| FaxNumber: | 3523310136 | ||||||||
| Practice Location | |||||||||
| Address1: | 6716 NW 11TH PLACE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523319729 | ||||||||
| FaxNumber: | 3523310136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2012 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9106653 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | P01080536 | 01 | FL | RAILROAD MEDICARE | OTHER | Y0C4P | 01 | FL | BCBS FL | OTHER | 006304500 | 05 | FL | MEDICAID | P01080540 | 01 | FL | RAILROAD MEDICARE | OTHER |