Provider Demographics
NPI:1902089253
Name:MARIE J GRAVEL INC
Entity Type:Organization
Organization Name:MARIE J GRAVEL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRAVEL
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:954-592-4292
Mailing Address - Street 1:3850 OAKS CLUBHOUSE DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-3668
Mailing Address - Country:US
Mailing Address - Phone:954-592-4292
Mailing Address - Fax:
Practice Address - Street 1:3850 OAKS CLUBHOUSE DR
Practice Address - Street 2:SUITE 206
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33069-3668
Practice Address - Country:US
Practice Address - Phone:954-592-4292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3729363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty