Healthcare Provider Details

I. General information

NPI: 1205232915
Provider Name (Legal Business Name): PA STAFFING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2014
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 BALLWIN AVE
BALLWIN MO
63021-5213
US

IV. Provider business mailing address

408 BALLWIN AVE
BALLWIN MO
63021-5213
US

V. Phone/Fax

Practice location:
  • Phone: 314-608-9438
  • Fax:
Mailing address:
  • Phone: 314-608-9438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2012008459
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2012008459
License Number StateMO

VIII. Authorized Official

Name: MR. JOSEPH JASON GRASSINO
Title or Position: OWNER
Credential: PA-C
Phone: 314-608-9438