Provider Demographics
NPI:1871726711
Name:GRAY, MARGO DIANE (NP)
Entity type:Individual
Prefix:
First Name:MARGO
Middle Name:DIANE
Last Name:GRAY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3046 CULLENS DR
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27253-5407
Mailing Address - Country:US
Mailing Address - Phone:336-214-5260
Mailing Address - Fax:
Practice Address - Street 1:10130 PERIMETER PKWY
Practice Address - Street 2:STE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-2447
Practice Address - Country:US
Practice Address - Phone:888-849-7379
Practice Address - Fax:855-857-7333
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5008662363LF0000X
KY3006128363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000639866OtherANTHEM BLUECROSS
KY710096140Medicaid
KY000000731911OtherANTHEM
KY710096140Medicaid
KY0989822Medicare PIN