Healthcare Provider Details

I. General information

NPI: 1417925363
Provider Name (Legal Business Name): GLENDA H GRAWE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45-549 PLUMERIA ST
HONOKAA HI
96727-6902
US

IV. Provider business mailing address

24847 FASSLER CIR
CHUGIAK AK
99567-5767
US

V. Phone/Fax

Practice location:
  • Phone: 808-775-7204
  • Fax: 808-775-9404
Mailing address:
  • Phone: 763-439-3390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberM4117
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21114
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number21114
License Number StateHI
# 4
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number186548-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: