Provider Demographics
NPI:1962624049
Name:GRAVATT, RAYNA (MD)
Entity type:Individual
Prefix:
First Name:RAYNA
Middle Name:
Last Name:GRAVATT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20970
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7020
Mailing Address - Country:US
Mailing Address - Phone:307-635-7961
Mailing Address - Fax:307-778-5812
Practice Address - Street 1:2301 HOUSE AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3176
Practice Address - Country:US
Practice Address - Phone:307-635-7961
Practice Address - Fax:307-637-8300
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7676A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1962624049Medicaid