Provider Demographics
NPI:1740234772
Name:GRAYKOSKI, JOHN JOSEPH (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:GRAYKOSKI
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:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:715-838-5222
Mailing Address - Fax:
Practice Address - Street 1:1222 E WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:BARRON
Practice Address - State:WI
Practice Address - Zip Code:54812-1765
Practice Address - Country:US
Practice Address - Phone:715-537-3166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1944023207P00000X, 207PE0004X, 207PP0204X, 207PT0002X
WI1944363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42883800Medicaid
WI0792 00502Medicare PIN