Provider Demographics
NPI:1134109077
Name:GRAVELL, WAYNE C (RPAC)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:C
Last Name:GRAVELL
Suffix:
Gender:M
Credentials:RPAC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2215 BURDETT AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-2466
Mailing Address - Country:US
Mailing Address - Phone:518-271-3311
Mailing Address - Fax:518-271-3919
Practice Address - Street 1:2215 BURDETT AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2466
Practice Address - Country:US
Practice Address - Phone:518-271-3311
Practice Address - Fax:518-271-3919
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
10051937OtherCD PHP
421559943OtherUNITED HEALTH CARE
NY040426007412OtherFIDELIS
00402959002OtherBLUE SHIELD NENY
421559943OtherUNITED HEALTH CARE