Provider Demographics
NPI:1578535241
Name:GRAUDONS, DOUGLAS SCOTT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:SCOTT
Last Name:GRAUDONS
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 1:4601 PARK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3239
Mailing Address - Country:US
Mailing Address - Phone:704-867-2333
Mailing Address - Fax:
Practice Address - Street 1:870 SUMMIT CROSSING PL
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2192
Practice Address - Country:US
Practice Address - Phone:704-867-2333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01685363A00000X
NY010054363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5691LEL241Medicare ID - Type Unspecified
NC0397730010Medicare NSC