Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363L00000X | Nurse Practitioner | 004862 | GA |
NPI | 1013004027 |
---|---|
Provider Name | Peter B Gray |
First Address | Clarkesville, GA 30523-6730 |
Second Address | Clarkesville, GA 30523-6730 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2006 |
Last Update Date | 05/01/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
870410301A | (05) | GA |
Q72635 | (02) | GA |