Provider Demographics
NPI:1568468437
Name:GRAVES, CLARENCE RICHARD III (PA-C)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:RICHARD
Last Name:GRAVES
Suffix:III
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:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-223-5646
Practice Address - Street 1:509 SE RIVERSIDE DR
Practice Address - Street 2:SUITE 203
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2579
Practice Address - Country:US
Practice Address - Phone:772-288-5862
Practice Address - Fax:772-288-5874
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0C06OtherFLORIDA BLUE
FL004802000Medicaid
FL004802000Medicaid