Basic Information
| Provider Information | |||||||||
| NPI: | 1710456280 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | LUKE | ||||||||
| MiddleName: | FREDERICK | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1035 W WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ALPENA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497072929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893580673 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3434 M 119 STE C | ||||||||
| Address2: | |||||||||
| City: | HARBOR SPRINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497409373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313489900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2018 | ||||||||
| LastUpdateDate: | 02/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601009547 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.