1356658512 NPI number — MRS. ANTONIA LARISSA GRAGG PA-C

Table of content: MRS. ANTONIA LARISSA GRAGG PA-C (NPI 1356658512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356658512 NPI number — MRS. ANTONIA LARISSA GRAGG PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAGG
Provider First Name:
ANTONIA
Provider Middle Name:
LARISSA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SOINEY
Provider Other First Name:
ANTONIA
Provider Other Middle Name:
LARISSA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356658512
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3303 SW BOND AVE
Provider Second Line Business Mailing Address:
CH8N
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97239-4501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-494-4314
Provider Business Mailing Address Fax Number:
503-346-6810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3303 SW BOND AVE
Provider Second Line Business Practice Location Address:
CH8N
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97239-4501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-494-4314
Provider Business Practice Location Address Fax Number:
503-346-6810
Provider Enumeration Date:
09/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA153285 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1356658512 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500635914 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com