Healthcare Provider Details

I. General information

NPI: 1568198224
Provider Name (Legal Business Name): NICHOLAS JOSEPH GRINNELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 N 5TH AVE
SEQUIM WA
98382-3045
US

IV. Provider business mailing address

81 STREIT RD
SEQUIM WA
98382-7553
US

V. Phone/Fax

Practice location:
  • Phone: 360-683-5900
  • Fax:
Mailing address:
  • Phone: 360-461-1133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61309930
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierPA61309930
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerPROVIDER CREDENTIAL NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: