Provider Demographics
NPI:1215351994
Name:GRAVES, GREG (PA-C)
Entity type:Individual
Prefix:MR
First Name:GREG
Middle Name:
Last Name:GRAVES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 N ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-4723
Mailing Address - Country:US
Mailing Address - Phone:775-786-3040
Mailing Address - Fax:775-786-1887
Practice Address - Street 1:555 N ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4723
Practice Address - Country:US
Practice Address - Phone:775-786-3040
Practice Address - Fax:775-357-9881
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-14
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1511363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100538896Medicaid
12671459OtherCAQH