Provider Demographics
NPI:1417906082
Name:GRAETHER, CLARENCE PAUL (PA-C)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:PAUL
Last Name:GRAETHER
Suffix:
Gender:M
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 1:66 KNIGHT LN STE 10
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-9308
Mailing Address - Country:US
Mailing Address - Phone:802-873-4343
Mailing Address - Fax:802-288-1144
Practice Address - Street 1:655 MAIN ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201
Practice Address - Country:US
Practice Address - Phone:802-258-3905
Practice Address - Fax:802-258-4903
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030210363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOAP2257Medicaid
VTAP2257Medicare ID - Type Unspecified
VTQ25824Medicare UPIN