Basic Information
| Provider Information | |||||||||
| NPI: | 1316970163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 126 STANWELL ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809067993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195760151 | ||||||||
| FaxNumber: | 7195382961 | ||||||||
| Practice Location | |||||||||
| Address1: | 3207 N ACADEMY BLVD STE 3500 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809175100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2003002307 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA.0002579 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 173190 | 01 | MO | BLUE CROSS BLUE SHIELD | OTHER | 523191 | 01 | MO | HEALTHLINK | OTHER |