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General NPI Number Information
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NPI Number | 1902089253
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Entity Type | Organization
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Legal Business Name | MARIE J GRAVEL INC
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Dates
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Enumeration Date | 12/10/2007
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Last Update Date | 12/10/2007
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Provider Practice Location Address
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Address Line | 3850 OAKS CLUBHOUSE DR SUITE 206
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City | POMPANO BEACH
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State | FL
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Zip | 33069-3668
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Country | US
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Telephone | 954-592-4292
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Fax |
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Provider Business Mailing Address
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Address Line | 3850 OAKS CLUBHOUSE DR SUITE 206
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City | POMPANO BEACH
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State | FL
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Zip | 33069-3668
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Country | US
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Telephone | 954-592-4292
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARIE J GRAVEL
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Credential | PA-C
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Telephone | 954-592-4292
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA3729
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License Number State | FL
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