Provider Demographics
NPI:1649401522
Name:GRAVINA, MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GRAVINA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17330 NORTHLAND PARK CT
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4318
Mailing Address - Country:US
Mailing Address - Phone:248-809-2853
Mailing Address - Fax:
Practice Address - Street 1:17330 NORTHLAND PARK CT
Practice Address - Street 2:SUITE 201
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4318
Practice Address - Country:US
Practice Address - Phone:248-809-2853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005451363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI262331509OtherTAX ID