Healthcare Provider Details

I. General information

NPI: 1538269774
Provider Name (Legal Business Name): CAROLYN ALFREDA GROOM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 IRVING ST NW
WASHINGTON DC
20422-0001
US

IV. Provider business mailing address

50 IRVING ST NW
WASHINGTON DC
20422-0001
US

V. Phone/Fax

Practice location:
  • Phone: 202-745-8295
  • Fax:
Mailing address:
  • Phone: 202-745-8295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number61
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: