Provider Demographics
NPI:1295777068
Name:GRIVETT, ELIZABETH ANN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANN
Last Name:GRIVETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:360 SAN MIGUEL DR
Mailing Address - Street 2:SUITE 501
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7853
Mailing Address - Country:US
Mailing Address - Phone:949-644-1025
Mailing Address - Fax:949-719-4930
Practice Address - Street 1:360 SAN MIGUEL DR
Practice Address - Street 2:SUITE 501
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7853
Practice Address - Country:US
Practice Address - Phone:949-644-1025
Practice Address - Fax:949-719-4930
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13761363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA13761COtherPERFORMING PHYSICIAN ID#
CAWPA13761COtherPERFORMING PHYSICIAN ID#