Healthcare Provider Details

I. General information

NPI: 1538064662
Provider Name (Legal Business Name): SHAWN TAYLOR GRIMSLEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 WOLF LAKE DR # 225A
GEORGETOWN TX
78628-3778
US

IV. Provider business mailing address

1101 WOLF LAKE DR # 225A
GEORGETOWN TX
78628-3778
US

V. Phone/Fax

Practice location:
  • Phone: 512-691-6511
  • Fax:
Mailing address:
  • Phone: 512-691-6511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA20840
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: