Provider Demographics
NPI:1255326385
Name:HARGRAVES, VAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:VAN
Middle Name:A
Last Name:HARGRAVES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:315 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:SUITE 142
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4234
Mailing Address - Country:US
Mailing Address - Phone:253-530-8080
Mailing Address - Fax:253-530-8099
Practice Address - Street 1:5551 WINGHAVEN BLVD
Practice Address - Street 2:SUITE 142
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-3617
Practice Address - Country:US
Practice Address - Phone:636-695-2510
Practice Address - Fax:636-695-2512
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2016-11-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO107781207Q00000X
WAMD60598761207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO080177925OtherRR MEDICARE
MO936714703Medicare PIN
MO080177925OtherRR MEDICARE
MO928824703Medicare PIN
MO14703Medicare PIN