Basic Information
Provider Information | |||||||||
NPI: | 1306157326 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAY | ||||||||
FirstName: | CHELSEY | ||||||||
MiddleName: | MICHELE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 95 E CHAUTAUQUA ST | ||||||||
Address2: |   | ||||||||
City: | MAYVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 147571017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7167537107 | ||||||||
FaxNumber: | 7167535367 | ||||||||
Practice Location | |||||||||
Address1: | 17 SHERMAN ST | ||||||||
Address2: | SUITE 2100 | ||||||||
City: | JAMESTOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 147017080 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7164836700 | ||||||||
FaxNumber: | 7166647275 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2010 | ||||||||
LastUpdateDate: | 08/21/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X |   |   | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.