Provider Demographics
NPI:1356658512
Name:GRAGG, ANTONIA LARISSA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANTONIA
Middle Name:LARISSA
Last Name:GRAGG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANTONIA
Other - Middle Name:LARISSA
Other - Last Name:SOINEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3303 SW BOND AVE
Mailing Address - Street 2:CH8N
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4501
Mailing Address - Country:US
Mailing Address - Phone:503-494-4314
Mailing Address - Fax:503-346-6810
Practice Address - Street 1:3303 SW BOND AVE
Practice Address - Street 2:CH8N
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-4314
Practice Address - Fax:503-346-6810
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA153285363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1356658512Medicaid
OR500635914Medicaid