Healthcare Provider Details

I. General information

NPI: 1790087187
Provider Name (Legal Business Name): BERNARD DEAN GROSE II PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2010
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 KANAWHA TER
SAINT ALBANS WV
25177-2750
US

IV. Provider business mailing address

12 KANAWHA TER
SAINT ALBANS WV
25177-2750
US

V. Phone/Fax

Practice location:
  • Phone: 304-201-1130
  • Fax: 304-201-1134
Mailing address:
  • Phone: 304-201-1130
  • Fax: 304-201-1134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number01522
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: