Healthcare Provider Details

I. General information

NPI: 1376027235
Provider Name (Legal Business Name): MEGAN DIANE GROSSMAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2438 N PONDEROSA DR STE C105
CAMARILLO CA
93010-2465
US

IV. Provider business mailing address

1125 E BROADWAY BOX 71
GLENDALE CA
91205-1315
US

V. Phone/Fax

Practice location:
  • Phone: 805-388-2068
  • Fax: 805-484-7700
Mailing address:
  • Phone: 818-790-1088
  • Fax: 818-790-1778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA55954
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: