Healthcare Provider Details

I. General information

NPI: 1942729819
Provider Name (Legal Business Name): THOMAS GRAVES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 PRIDES XING STE 200
NEWARK DE
19713-6109
US

IV. Provider business mailing address

700 PRIDES XING STE 200
NEWARK DE
19713-6109
US

V. Phone/Fax

Practice location:
  • Phone: 302-998-0300
  • Fax:
Mailing address:
  • Phone: 302-998-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberLG0001053
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG0001053
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: