Provider Demographics
NPI:1083326557
Name:GRAVEDONI, EVAN STEVEN (PA-C)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:STEVEN
Last Name:GRAVEDONI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1876 REDPINE DR
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-9123
Mailing Address - Country:US
Mailing Address - Phone:906-204-6550
Mailing Address - Fax:
Practice Address - Street 1:1320 M-32
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735
Practice Address - Country:US
Practice Address - Phone:989-731-5092
Practice Address - Fax:989-705-8323
Is Sole Proprietor?:No
Enumeration Date:2022-12-15
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601012281363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant