Healthcare Provider Details

I. General information

NPI: 1518907799
Provider Name (Legal Business Name): ANDREA M GRIMM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA M WINKLE PA-C

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 05/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT JOSEPH DR
LEXINGTON KY
40504-3742
US

IV. Provider business mailing address

1431 CENTERPOINT BLVD
KNOXVILLE TN
37932-1984
US

V. Phone/Fax

Practice location:
  • Phone: 859-313-1176
  • Fax: 859-313-3586
Mailing address:
  • Phone: 865-985-7221
  • Fax: 865-560-7114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number00772
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2074
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: