Provider Demographics
NPI:1346400975
Name:GRAVES, MARTA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:
Last Name:GRAVES
Suffix:
Gender:F
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 1:5861 CANYON WAY
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:CO
Mailing Address - Zip Code:80504-5649
Mailing Address - Country:US
Mailing Address - Phone:773-220-8952
Mailing Address - Fax:
Practice Address - Street 1:100 KAHELU AVE STE 226
Practice Address - Street 2:
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-3962
Practice Address - Country:US
Practice Address - Phone:808-621-1000
Practice Address - Fax:808-627-6000
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0002659363A00000X
HIAMD-1218363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98839225Medicaid