Provider Demographics
NPI:1124513817
Name:GRAY, NICHOLAS JOHN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOHN
Last Name:GRAY
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7026 OLD KATY RD STE 276
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-2187
Mailing Address - Country:US
Mailing Address - Phone:713-358-0562
Mailing Address - Fax:
Practice Address - Street 1:7026 OLD KATY RD STE 276
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-2187
Practice Address - Country:US
Practice Address - Phone:713-358-0562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
TXPA12186363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171000000XOther Service ProvidersMilitary Health Care Provider