Provider Demographics
NPI:1538558754
Name:GRAY, KAITLYN (PA-C)
Entity type:Individual
Prefix:MS
First Name:KAITLYN
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 OXFORD STREET, SUITE220
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622
Mailing Address - Country:US
Mailing Address - Phone:330-440-0715
Mailing Address - Fax:330-364-8022
Practice Address - Street 1:340 OXFORD ST STE 220
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-1967
Practice Address - Country:US
Practice Address - Phone:330-440-0715
Practice Address - Fax:330-364-8022
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004128363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant