MEDICARE: MR. GREGORY SYMENOW PA-C

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	0010-10218	NC
2	363A00000X	Physician Assistant	5601010944	MI
3	363A00000X	Physician Assistant	085.008777	IL
4	363A00000X	Physician Assistant	027730	NY
5	363A00000X	Physician Assistant	50.007382	OH
6	363AM0700X	Medical Physician Assistant	0110003771	VA

General Provider Information

NPI Number	:	1245516459
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGORY SYMENOW PA-C

Provider Business Mailing Address
First Line	:	12025 SHORTLEAF LN
Second Line	:
City	:	ROCKVILLE
State	:	VA
Zip	:	23146-1859
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3550 PINE GROVE AVE
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-1944
Country	:	US
Telephone Number	:	833-620-1234
Fax Number	:

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

Provider Enumeration Date	:	11/01/2011
Last Update Date	:	12/29/2022

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