Provider Demographics
NPI:1417056490
Name:GRAVETT, MICHAEL CHRISTIAN (MPA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHRISTIAN
Last Name:GRAVETT
Suffix:
Gender:M
Credentials:MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CLINIC AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 CLINIC AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4401
Practice Address - Country:US
Practice Address - Phone:770-834-0873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ44916_Medicare UPIN
GA97WCGPCMedicare PIN