Provider Demographics
NPI:1710233515
Name:MITCHELL, MOLLY GRAVES (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:GRAVES
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:ELIZABETH
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:2097 HENRY TECKLENBURG DR STE 312W
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414
Practice Address - Country:US
Practice Address - Phone:843-789-1800
Practice Address - Fax:843-606-8036
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2337363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2456PAMedicaid