Healthcare Provider Details

I. General information

NPI: 1104229699
Provider Name (Legal Business Name): CARYN R GRIM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARYN PETERSON

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 FLEMINGSBURG RD
MOREHEAD KY
40351-1810
US

IV. Provider business mailing address

3480 YORKSHIRE MEDICAL PARK
LEXINGTON KY
40509-1886
US

V. Phone/Fax

Practice location:
  • Phone: 859-263-5140
  • Fax: 859-263-5141
Mailing address:
  • Phone: 859-263-5140
  • Fax: 859-263-5141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1923
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberTC294
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: