Provider Demographics
NPI:1538410113
Name:GRAY, MADISYN LYNN (PA)
Entity type:Individual
Prefix:MRS
First Name:MADISYN
Middle Name:LYNN
Last Name:GRAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5008
Mailing Address - Country:US
Mailing Address - Phone:616-685-8348
Mailing Address - Fax:616-685-8099
Practice Address - Street 1:250 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4608
Practice Address - Country:US
Practice Address - Phone:616-685-6756
Practice Address - Fax:616-685-3086
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601006467363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN82690005Medicare PIN