Healthcare Provider Details

I. General information

NPI: 1023000528
Provider Name (Legal Business Name): JASON DAVID GRABROVAC PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 NORTHSIDE FORSYTH DR SUITE 340
CUMMING GA
30041-6012
US

IV. Provider business mailing address

1100 NORTHSIDE FORSYTH DR SUITE 340
CUMMING GA
30041-6012
US

V. Phone/Fax

Practice location:
  • Phone: 770-886-8111
  • Fax: 770-205-8539
Mailing address:
  • Phone: 770-886-8111
  • Fax: 770-205-8539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004057
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: