Basic Information
| Provider Information | |||||||||
| NPI: | 1053040493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARGRAVES | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | BENSON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1456 N 800 E | ||||||||
| Address2: | |||||||||
| City: | SHELLEY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832745014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088212412 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1090 W PARK PL | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086205250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2022 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.