Provider Demographics
NPI:1851772438
Name:GRAVENSTEIN, KATHRYN CHARLOTTE ANDERSON (PA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:CHARLOTTE ANDERSON
Last Name:GRAVENSTEIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:CHARLOTTE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13020 N TELECOM PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0915
Mailing Address - Country:US
Mailing Address - Phone:813-978-9700
Mailing Address - Fax:
Practice Address - Street 1:13020 N TELECOM PKWY
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0915
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108773363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9108773OtherMEDICAL LICENSE
FL015355200Medicaid
FL015355200Medicaid