Provider Demographics
NPI:1245662535
Name:GREAVES, AMY LUCAS (PA-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LUCAS
Last Name:GREAVES
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:LUCAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:165 SHERMAN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9811
Mailing Address - Country:US
Mailing Address - Phone:802-748-9405
Mailing Address - Fax:802-748-4540
Practice Address - Street 1:137 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-4415
Practice Address - Country:US
Practice Address - Phone:802-995-2412
Practice Address - Fax:802-334-7991
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0968363A00000X
VT055.0031667363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT055.0031667OtherVT STATE LICENSE
NH0968OtherNH LICENSE