MEDICARE: JACOB ADAM GRILLO PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	363AM0700X	Medical Physician Assistant

General Provider Information

NPI Number	:	1043612575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB ADAM GRILLO PA-C

Provider Business Mailing Address
First Line	:	809 W MAIN ST STE C
Second Line	:
City	:	MONROE
State	:	WA
Zip	:	98272-2172
Country	:	US
Telephone Number	:	206-552-0882
Fax Number	:

Provider Business Practice Location Address
First Line	:	809 W MAIN ST STE C
Second Line	:
City	:	MONROE
State	:	WA
Zip	:	98272-2172
Country	:	US
Telephone Number	:	206-552-0882
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2014
Last Update Date	:	06/12/2024

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