Healthcare Provider Details

I. General information

NPI: 1093797250
Provider Name (Legal Business Name): KRISTIN MARIE GROESSL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4409 NW ANDERSON HILL RD
SILVERDALE WA
98383-6807
US

IV. Provider business mailing address

4409 NW ANDERSON HILL RD
SILVERDALE WA
98383-6807
US

V. Phone/Fax

Practice location:
  • Phone: 360-698-6630
  • Fax: 360-698-7002
Mailing address:
  • Phone: 360-698-6630
  • Fax: 360-698-7002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61092965
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1164-023
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1164-023
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number56266
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA61092965
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: