# GORDON BRADLEY GREAVES

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** Yes

## Provider details

- **NPI number:** 1699708131
- **Gender:** Man
- **Credential:** PA

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363A00000X | Physician Assistant | 16369 | CA | — |
| 363A00000X | Physician Assistant | PA615 | ID | Yes |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | PA615 | ID | — |

## Other

- **Enumeration date:** 07/08/2006
- **Last updated:** 04/14/2025

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 16369 | PA LICENSE | CA |
| 05 | — | 807537400 | — | ID |
| 01 | — | PA615 | IDAHO BOARD OF MEDICINE | ID |