Provider Demographics
NPI:1013982909
Name:GRAVES, ERNIE L (PA)
Entity Type:Individual
Prefix:MR
First Name:ERNIE
Middle Name:L
Last Name:GRAVES
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 1:213 RIVER WALK PKY
Mailing Address - Street 2:STE 101
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320
Mailing Address - Country:US
Mailing Address - Phone:757-548-1400
Mailing Address - Fax:757-548-2312
Practice Address - Street 1:213 RIVER WALK PKY
Practice Address - Street 2:STE 101
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320
Practice Address - Country:US
Practice Address - Phone:757-548-1400
Practice Address - Fax:757-548-2312
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840536363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008944962Medicaid
970000210Medicare ID - Type Unspecified
S54270Medicare UPIN