Provider Demographics
NPI:1194784405
Name:GRAY, CARRIE JEAN (PA C)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:JEAN
Last Name:GRAY
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:JEAN
Other - Last Name:GAULEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2025 SLOAN PL
Mailing Address - Street 2:SUITE 35
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2007
Mailing Address - Country:US
Mailing Address - Phone:651-772-1572
Mailing Address - Fax:651-772-1889
Practice Address - Street 1:911 MARYLAND AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-2697
Practice Address - Country:US
Practice Address - Phone:651-776-2719
Practice Address - Fax:651-771-3978
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10404363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN958157000Medicaid
P01145Medicare UPIN