Provider Demographics
NPI:1104802990
Name:GRAY, PAMELA SUE (NP)
Entity type:Individual
Prefix:MR
First Name:PAMELA
Middle Name:SUE
Last Name:GRAY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:341 LONESOME OAK DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48306-2836
Mailing Address - Country:US
Mailing Address - Phone:248-898-4760
Mailing Address - Fax:242-898-3127
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-4760
Practice Address - Fax:248-898-3127
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4704091393363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON26750Medicare UPIN
MION25690009Medicare ID - Type UnspecifiedMEDICARE ID#