Provider Demographics
NPI:1285392464
Name:GRAY, ROBERT ELLIOTT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ELLIOTT
Last Name:GRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 UNION RD
Mailing Address - Street 2:STE A
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2201
Mailing Address - Country:US
Mailing Address - Phone:704-867-6188
Mailing Address - Fax:704-866-4437
Practice Address - Street 1:1530 UNION RD STE A
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2201
Practice Address - Country:US
Practice Address - Phone:704-867-6188
Practice Address - Fax:704-866-4437
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2023-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty