Provider Demographics
NPI:1104982628
Name:GREY, EARLE C (PA)
Entity type:Individual
Prefix:MR
First Name:EARLE
Middle Name:C
Last Name:GREY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2727 W DR MLK BLVD STE 460
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6001
Mailing Address - Country:US
Mailing Address - Phone:813-879-4328
Mailing Address - Fax:813-873-2391
Practice Address - Street 1:2727 W DR MLK BLVD STE 460
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6001
Practice Address - Country:US
Practice Address - Phone:813-879-4328
Practice Address - Fax:813-873-2391
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9108320363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013890700Medicaid
FLIA364ZMedicare PIN
021627M21Medicare PIN
FL013890700Medicaid
P00450292Medicare PIN