Provider Demographics
NPI:1316970163
Name:GRAY, CHARLES RICHARD (PA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:RICHARD
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 1:4790 FARTHING DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906
Mailing Address - Country:US
Mailing Address - Phone:719-963-7579
Mailing Address - Fax:719-538-2961
Practice Address - Street 1:3207 N ACADEMY BLVD STE 3500
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5100
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003002307363A00000X
COPA.0002579363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO523191OtherHEALTHLINK
MO173190OtherBLUE CROSS BLUE SHIELD
MO173190OtherBLUE CROSS BLUE SHIELD
P00431084Medicare PIN
IL212557Medicare PIN
K36037Medicare PIN
MO523191OtherHEALTHLINK