Healthcare Provider Details

I. General information

NPI: 1699708131
Provider Name (Legal Business Name): GORDON BRADLEY GREAVES PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: G BRAD GREAVES PA

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15821 ALLENDALE RD
WILDER ID
83676-5864
US

IV. Provider business mailing address

15821 ALLENDALE RD
WILDER ID
83676-5864
US

V. Phone/Fax

Practice location:
  • Phone: 208-278-2863
  • Fax: 208-621-3128
Mailing address:
  • Phone: 208-278-2863
  • Fax: 208-621-3128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number16369
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberPA615
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA615
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: