Healthcare Provider Details

I. General information

NPI: 1780010967
Provider Name (Legal Business Name): VALERI GRAVE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 12/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8971 W OVERLAND RD
BOISE ID
83709-1651
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-378-4288
  • Fax: 208-378-4297
Mailing address:
  • Phone: 208-955-6522
  • Fax: 208-955-6503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0003782
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0003782
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1220
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: