Provider Demographics
NPI:1184633935
Name:PATE, KELLY ELIZABETH GRAVER (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH GRAVER
Last Name:PATE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:9279 LOCUST ST.
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95669
Practice Address - Country:US
Practice Address - Phone:209-245-6968
Practice Address - Fax:209-245-5135
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18164363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0078351OtherMEDICAL
CAZZZ13862ZMedicare PIN