Provider Demographics
NPI:1578798096
Name:GRAY, KATHLEEN MARIE (PA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:GRAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:GODINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1223 MERCY DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1829
Mailing Address - Country:US
Mailing Address - Phone:231-672-2120
Mailing Address - Fax:313-432-7758
Practice Address - Street 1:1223 MERCY DR
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1829
Practice Address - Country:US
Practice Address - Phone:231-672-3500
Practice Address - Fax:313-432-7758
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN27530063OtherMEDICARE