=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750989760
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOKE JOSEPHINE GRIGGS MPAS, PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2020
-----------------------------------------------------
Last Update Date | 10/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3920 N OCEAN DR APT 2A
-----------------------------------------------------
City | RIVIERA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33404-2889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-733-8405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3920 N OCEAN DR APT 2A
-----------------------------------------------------
City | RIVIERA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33404-2889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-733-8405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | PA9113713
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------