Provider Demographics
NPI:1891472650
Name:GRAVGAARD, TIM
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:GRAVGAARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 MATTHEWS DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-7739
Mailing Address - Country:US
Mailing Address - Phone:757-618-9866
Mailing Address - Fax:
Practice Address - Street 1:117 MATTHEWS DR
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-7739
Practice Address - Country:US
Practice Address - Phone:757-618-9866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20899329172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver