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Individual
GORDON BRADLEY GREAVES
Active
Individual
GORDON BRADLEY GREAVES
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
16369
CA
363A00000X
Physician Assistant
Primary
PA615
ID
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
PA615
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
16369
PA LICENSE
CA
05
—
807537400
—
ID
01
—
PA615
IDAHO BOARD OF MEDICINE
ID
Enumeration date
07/08/2006
Last updated
04/14/2025
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