Provider Demographics
NPI:1578545281
Name:GRAVGAARD, JOHN (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GRAVGAARD
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 SWEET BAY RD
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-2127
Mailing Address - Country:US
Mailing Address - Phone:478-224-0294
Mailing Address - Fax:
Practice Address - Street 1:655 7TH ST
Practice Address - Street 2:78 MDG/SGOMF
Practice Address - City:ROBINS AFB
Practice Address - State:GA
Practice Address - Zip Code:31098-2227
Practice Address - Country:US
Practice Address - Phone:478-327-7880
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1028021363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant