Provider Demographics
NPI:1184323487
Name:GRAY, JAMES LANCE
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:LANCE
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 1:808 N FRANKLIN ST UNIT 1906
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-3842
Mailing Address - Country:US
Mailing Address - Phone:573-429-8154
Mailing Address - Fax:
Practice Address - Street 1:1525 W CYPRESS CREEK RD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1831
Practice Address - Country:US
Practice Address - Phone:573-429-8154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9453566367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered