Provider Demographics
NPI:1487369799
Name:GRAY, CULLEN HERCULES
Entity type:Individual
Prefix:
First Name:CULLEN
Middle Name:HERCULES
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 1:522 S SAN PEDRO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-2102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:522 S SAN PEDRO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013
Practice Address - Country:US
Practice Address - Phone:562-867-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-20
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64044363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant