=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720695224
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN T HARGRAVE NP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2020
-----------------------------------------------------
Last Update Date | 04/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 575 N SIOUX POINT RD
-----------------------------------------------------
City | DAKOTA DUNES
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57049-5312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-217-2667
-----------------------------------------------------
Fax | 605-217-2900
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 575 N SIOUX POINT RD
-----------------------------------------------------
City | DAKOTA DUNES
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57049-5312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-217-2667
-----------------------------------------------------
Fax | 605-217-2900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | A160877
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 113865
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | CP002047
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------