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General NPI Number Information
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NPI Number | 1396151395
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Entity Type | Individual
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Provider Name | JENNIFER GRINAGE PA-C
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Gender | Female
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Dates
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Enumeration Date | 07/10/2014
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Last Update Date | 11/14/2024
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Provider Practice Location Address
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Address Line | 222 SOUTHWAY AVE STE C
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City | LEWISTON
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State | ID
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Zip | 83501-2703
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Country | US
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Telephone | 208-792-0111
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Fax |
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Provider Business Mailing Address
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Address Line | 1200 NORA CREEK RD
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City | TROY
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State | ID
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Zip | 83871-9647
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Country | US
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Telephone | 208-792-1011
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA1175
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License Number State | ID
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