Basic Information
| Provider Information | |||||||||
| NPI: | 1194019398 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | TASHARA | ||||||||
| MiddleName: | NATASHJA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARTIN | ||||||||
| OtherFirstName: | TASHARA | ||||||||
| OtherMiddleName: | NATASHJA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3033 N CENTRAL AVE STE 145 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778095092 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 306 MONROE AVENUE | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778095092 | ||||||||
| FaxNumber: | 6238159253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2011 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | LL33679 | SC | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | ME119054 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 61785 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 012046900 | 05 | FL | MEDICAID |