Provider Demographics
NPI:1710063995
Name:GRACY, JAMES (PA)
Entity Type:Individual
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First Name:JAMES
Middle Name:
Last Name:GRACY
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:2390 MITCHELL PARK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8965
Mailing Address - Country:US
Mailing Address - Phone:231-487-9090
Mailing Address - Fax:231-487-9191
Practice Address - Street 1:2390 MITCHELL PARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8965
Practice Address - Country:US
Practice Address - Phone:231-487-9090
Practice Address - Fax:231-487-9191
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2009-10-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601001920363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN57190003Medicare PIN
S67358Medicare UPIN