Provider Demographics
NPI:1285770321
Name:BRAY, GORDON (CRNA)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:
Last Name:BRAY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N RIVER ST
Mailing Address - Street 2:
Mailing Address - City:CLAXTON
Mailing Address - State:GA
Mailing Address - Zip Code:30417-1659
Mailing Address - Country:US
Mailing Address - Phone:912-739-5297
Mailing Address - Fax:912-739-5101
Practice Address - Street 1:200 N RIVER ST
Practice Address - Street 2:
Practice Address - City:CLAXTON
Practice Address - State:GA
Practice Address - Zip Code:30417-1659
Practice Address - Country:US
Practice Address - Phone:912-739-5297
Practice Address - Fax:912-739-5101
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN030371367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00908927AMedicaid