=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376027235
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN DIANE GROSSMAN PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2018
-----------------------------------------------------
Last Update Date | 07/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2438 N PONDEROSA DR STE C105
-----------------------------------------------------
City | CAMARILLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93010-2465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-388-2068
-----------------------------------------------------
Fax | 805-484-7700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1125 E BROADWAY BOX 71
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91205-1315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-790-1088
-----------------------------------------------------
Fax | 818-790-1778
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA55954
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------