Healthcare Provider Details

I. General information

NPI: 1720695224
Provider Name (Legal Business Name): JUSTIN T HARGRAVE NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 N SIOUX POINT RD
DAKOTA DUNES SD
57049-5312
US

IV. Provider business mailing address

575 N SIOUX POINT RD
DAKOTA DUNES SD
57049-5312
US

V. Phone/Fax

Practice location:
  • Phone: 605-217-2667
  • Fax: 605-217-2900
Mailing address:
  • Phone: 605-217-2667
  • Fax: 605-217-2900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA160877
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number113865
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP002047
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: