Provider Demographics
NPI:1053040493
Name:HARGRAVES, JEFFREY BENSON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:BENSON
Last Name:HARGRAVES
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 1:1456 N 800 E
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-5014
Mailing Address - Country:US
Mailing Address - Phone:208-821-2412
Mailing Address - Fax:
Practice Address - Street 1:1090 W PARK PL
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2785
Practice Address - Country:US
Practice Address - Phone:208-620-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty