Provider Demographics
NPI:1861589749
Name:GRAY, MARISSA LEE (PA-C)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:LEE
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 1:11001 DURANT RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8390
Mailing Address - Country:US
Mailing Address - Phone:919-781-2500
Mailing Address - Fax:919-781-9247
Practice Address - Street 1:11001 DURANT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8390
Practice Address - Country:US
Practice Address - Phone:919-781-2500
Practice Address - Fax:919-781-9247
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103621363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical