Provider Demographics
NPI:1174259154
Name:GRAVES, MARISSA (PA-C)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:GRAVES
Suffix:
Gender:F
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 1:4593 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-1131
Mailing Address - Country:US
Mailing Address - Phone:760-831-5349
Mailing Address - Fax:
Practice Address - Street 1:6719 ALVARADO RD STE 308
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5268
Practice Address - Country:US
Practice Address - Phone:619-784-4439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1174748OtherNCCPA
CA60836OtherPHYSICIAN ASSISTANT BOARD- THE MEDICAL BOARD OF CALIFORNIA