Provider Demographics
NPI:1699708131
Name:GREAVES, GORDON BRADLEY (PA)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:BRADLEY
Last Name:GREAVES
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:G
Other - Middle Name:BRAD
Other - Last Name:GREAVES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:15821 ALLENDALE RD
Mailing Address - Street 2:
Mailing Address - City:WILDER
Mailing Address - State:ID
Mailing Address - Zip Code:83676-5864
Mailing Address - Country:US
Mailing Address - Phone:208-278-2863
Mailing Address - Fax:208-621-3128
Practice Address - Street 1:15821 ALLENDALE RD
Practice Address - Street 2:
Practice Address - City:WILDER
Practice Address - State:ID
Practice Address - Zip Code:83676-5864
Practice Address - Country:US
Practice Address - Phone:208-278-2863
Practice Address - Fax:208-621-3128
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16369363A00000X
IDPA615363LP0808X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807537400Medicaid
CA16369OtherPA LICENSE
IDPA615OtherIDAHO BOARD OF MEDICINE
ID807537400Medicaid