Provider Demographics
NPI:1215990601
Name:GRAY, LEE ALEXANDER (PA)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:ALEXANDER
Last Name:GRAY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 FRONTIS PLAZA BLVD STE 200
Mailing Address - Street 2:ATTN FORSYTH MEDICAL GROUP
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5616
Mailing Address - Country:US
Mailing Address - Phone:336-277-2436
Mailing Address - Fax:
Practice Address - Street 1:111 GATEWAY CENTER DR
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-2999
Practice Address - Country:US
Practice Address - Phone:336-996-2173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101970363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S01768Medicare UPIN
NC2751944Medicare ID - Type Unspecified