Healthcare Provider Details

I. General information

NPI: 1184633935
Provider Name (Legal Business Name): KELLY ELIZABETH GRAVER PATE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY ELIZABETH GRAVES

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9279 LOCUST ST.
JACKSON CA
95669
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD STE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 209-245-6968
  • Fax: 209-245-5135
Mailing address:
  • Phone: 800-470-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA18164
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: