Provider Demographics
NPI:1619653292
Name:GRADEN, MATTHEW PAUL
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PAUL
Last Name:GRADEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 STONEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:PA
Mailing Address - Zip Code:17078-4408
Mailing Address - Country:US
Mailing Address - Phone:717-712-6613
Mailing Address - Fax:
Practice Address - Street 1:25 STATE AVE
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17013-4420
Practice Address - Country:US
Practice Address - Phone:717-249-4948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG004022152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist