Provider Demographics
NPI:1447505052
Name:GRAY, MATTHEW JEREMY
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JEREMY
Last Name:GRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27261-2168
Mailing Address - Country:US
Mailing Address - Phone:336-882-2567
Mailing Address - Fax:336-882-5466
Practice Address - Street 1:401 FERNDALE BLVD
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4739
Practice Address - Country:US
Practice Address - Phone:336-882-2567
Practice Address - Fax:336-882-5466
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC216669163W00000X
NC091089367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8054265Medicaid
NCQ40992AMedicare PIN