Provider Demographics
NPI:1174691869
Name:GRAVEL SOLANO, MARIE J (PA-C)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:J
Last Name:GRAVEL SOLANO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:J
Other - Last Name:GRAVEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4725 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4603
Mailing Address - Country:US
Mailing Address - Phone:954-958-4800
Mailing Address - Fax:
Practice Address - Street 1:4725 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4603
Practice Address - Country:US
Practice Address - Phone:954-958-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3729363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA3729OtherLICENSE
FLS80451Medicare UPIN
FLE2526YMedicare ID - Type Unspecified