MEDICARE: CLARENCE RICHARD GRAVES III 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	363A00000X	Physician Assistant	PA9106480	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y0C06	OTHER	FL	FLORIDA BLUE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568468437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARENCE RICHARD GRAVES III PA-C

Provider Business Mailing Address
First Line	:	PO BOX 417
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34995-0417
Country	:	US
Telephone Number	:	772-223-2832
Fax Number	:	772-223-5646

Provider Business Practice Location Address
First Line	:	509 SE RIVERSIDE DR
Second Line	:	SUITE 203
City	:	STUART
State	:	FL
Zip	:	34994-2579
Country	:	US
Telephone Number	:	772-288-5862
Fax Number	:	772-288-5874

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

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	10/09/2020

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