Provider Demographics
NPI:1952787764
Name:GRAVGAARD, JONATHAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:GRAVGAARD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 WEBER RIDGE PT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-7000
Mailing Address - Country:US
Mailing Address - Phone:678-468-3068
Mailing Address - Fax:
Practice Address - Street 1:3630 SINTON RD STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-5072
Practice Address - Country:US
Practice Address - Phone:719-359-8812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-04
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2396363AM0700X
COPA.0004875363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant