Provider Demographics
NPI:1306904966
Name:GREGORY, KERRY (PA)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:GREGORY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 RIDGELY AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-1001
Mailing Address - Country:US
Mailing Address - Phone:410-266-8049
Mailing Address - Fax:410-266-0895
Practice Address - Street 1:600 RIDGELY AVE
Practice Address - Street 2:SUTIE 130
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1001
Practice Address - Country:US
Practice Address - Phone:410-266-8049
Practice Address - Fax:410-266-0895
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1070062363A00000X
MDC03923363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant