Basic Information
| Provider Information | |||||||||
| NPI: | 1750681516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAVETT | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GRAVETT | ||||||||
| OtherFirstName: | MATTHEW | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 890 W ELLIOT RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852335127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052340080 | ||||||||
| FaxNumber: | 9198829575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1895 W VALENCIA RD # 101 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857466555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205765104 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2010 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 52388 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | CB241808 | 01 | CA | MEDICARE ID | OTHER |