Healthcare Provider Details

I. General information

NPI: 1356658512
Provider Name (Legal Business Name): ANTONIA LARISSA GRAGG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANTONIA LARISSA SOINEY PA-C

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 07/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 SW BOND AVE CH8N
PORTLAND OR
97239-4501
US

IV. Provider business mailing address

3303 SW BOND AVE CH8N
PORTLAND OR
97239-4501
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-4314
  • Fax: 503-346-6810
Mailing address:
  • Phone: 503-494-4314
  • Fax: 503-346-6810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA153285
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: