Healthcare Provider Details

I. General information

NPI: 1740321090
Provider Name (Legal Business Name): BROOK ASHLEE GRAM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18586 5TH ST
BELOIT OH
44609-9799
US

IV. Provider business mailing address

2242 PARKWAY BLVD
ALLIANCE OH
44601-4650
US

V. Phone/Fax

Practice location:
  • Phone: 330-938-3333
  • Fax: 330-938-9375
Mailing address:
  • Phone: 330-823-7855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2565
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: