MEDICARE: JESSICA LAURA GRAVES PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA2129	OK
2	363A00000X	Physician Assistant	AMD-770	HI

General Provider Information

NPI Number	:	1407120066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LAURA GRAVES PA-C

Provider Business Mailing Address
First Line	:	4700 W URBANA ST STE 100
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-5520
Country	:	US
Telephone Number	:	539-281-3101
Fax Number	:

Provider Business Practice Location Address
First Line	:	4700 W URBANA ST STE 100
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-5520
Country	:	US
Telephone Number	:	539-281-3101
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/29/2012
Last Update Date	:	05/18/2026

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