MEDICARE: GRACE LO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1174286181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE LO

Provider Business Mailing Address
First Line	:	5850 E STILL CIR
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-3618
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4211 FAIRMONT PKWY
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77504-3324
Country	:	US
Telephone Number	:	281-481-9400
Fax Number	:	281-481-9490

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2021
Last Update Date	:	08/13/2024

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Directions to “ GRACE LO ” Practice Location

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