Provider Demographics
NPI:1962515684
Name:GRAY, TODD (PA)
Entity type:Individual
Prefix:MR
First Name:TODD
Middle Name:
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 1:1305 RIVER BIRCH PL
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-3294
Mailing Address - Country:US
Mailing Address - Phone:301-283-5475
Mailing Address - Fax:
Practice Address - Street 1:268 BROOKLEY AVE
Practice Address - Street 2:
Practice Address - City:BOLLING AFB
Practice Address - State:DC
Practice Address - Zip Code:20032
Practice Address - Country:US
Practice Address - Phone:202-404-3603
Practice Address - Fax:202-404-1256
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant