Basic Information
| Provider Information | |||||||||
| NPI: | 1760025092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAVES | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | FRANCES | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2867 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366522867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516908158 | ||||||||
| FaxNumber: | 2515442188 | ||||||||
| Practice Location | |||||||||
| Address1: | 5580 INN RD | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366191904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516667413 | ||||||||
| FaxNumber: | 2516667417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2019 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.1536 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 242341 | 05 | AL | MEDICAID | 242790 | 05 | AL | MEDICAID | 242269 | 05 | AL | MEDICAID | 242349 | 05 | AL | MEDICAID | 242369 | 05 | AL | MEDICAID | 242791 | 05 | AL | MEDICAID | 242342 | 05 | AL | MEDICAID | 242534 | 05 | AL | MEDICAID | 242694 | 05 | AL | MEDICAID |