Provider Demographics
NPI:1750681516
Name:GRAVETT, MATTHEW LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEE
Last Name:GRAVETT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:
Other - Last Name:GRAVETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:5055 E BROADWAY BLVD STE A100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3629
Mailing Address - Country:US
Mailing Address - Phone:520-795-4729
Mailing Address - Fax:520-547-5797
Practice Address - Street 1:1400 W VALENCIA RD STE 110
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85746-6006
Practice Address - Country:US
Practice Address - Phone:520-751-3335
Practice Address - Fax:520-547-4786
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52388363A00000X
AZ6934363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB241808OtherMEDICARE ID
CO57235066Medicaid
NM23985038Medicaid