Provider Demographics
NPI:1063132587
Name:GRAVES, JOHNATHAN
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:GRAVES
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 1:220 CAMDEN WOODS DR
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27360-8911
Mailing Address - Country:US
Mailing Address - Phone:336-880-2106
Mailing Address - Fax:
Practice Address - Street 1:220 CAMDEN WOODS DR
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-8911
Practice Address - Country:US
Practice Address - Phone:336-880-2106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27528652343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)