Provider Demographics
NPI:1902426851
Name:CARTER, GRADY GERALD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GRADY
Middle Name:GERALD
Last Name:CARTER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3853 ASHGLEN DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-7637
Mailing Address - Country:US
Mailing Address - Phone:904-930-5056
Mailing Address - Fax:
Practice Address - Street 1:100 WHETSTONE PL STE 102
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5775
Practice Address - Country:US
Practice Address - Phone:904-342-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113401363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical