Healthcare Provider Details

I. General information

NPI: 1740468388
Provider Name (Legal Business Name): TAMMY JEAN GROSSERODE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5330 N OAK TRFY SUITE 200
KANSAS CITY MO
64118-4699
US

IV. Provider business mailing address

5810 NW BARRY RD STE 100
KANSAS CITY MO
64154-1400
US

V. Phone/Fax

Practice location:
  • Phone: 816-454-0666
  • Fax: 816-454-1694
Mailing address:
  • Phone: 816-454-0666
  • Fax: 816-454-1694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2006024407
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: