Basic Information
| Provider Information | |||||||||
| NPI: | 1871726711 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | MARGO | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3046 CULLENS DR | ||||||||
| Address2: | |||||||||
| City: | GRAHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272535407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362145260 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10130 PERIMETER PKWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282162447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888497379 | ||||||||
| FaxNumber: | 8558577333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2009 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5008662 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 3006128 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 000000639866 | 01 | KY | ANTHEM BLUECROSS | OTHER | 710096140 | 05 | KY | MEDICAID | 000000731911 | 01 | KY | ANTHEM | OTHER |