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NPI Code Detail

MEDICARE: MYRISSA GROVE

MEDICARE: MYRISSA GROVE
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
1363AM0700XMedical Physician AssistantPA.0008496CO

General Provider Information

NPI Number : 1063245447
Entity Type Code : Individual
Provider Name (Legal Business Name) : MYRISSA GROVE
Provider Business Mailing Address
First Line : 2759 SCOTCHBROOM PT
Second Line :
City : COLORADO SPRINGS
State : CO
Zip : 80910-4452
Country : US
Telephone Number : 715-456-6400
Fax Number :
Provider Business Practice Location Address
First Line : 2759 SCOTCHBROOM PT
Second Line :
City : COLORADO SPRINGS
State : CO
Zip : 80910-4452
Country : US
Telephone Number : 715-456-6400
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/21/2024
Last Update Date : 08/21/2024

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Directions to “ MYRISSA GROVE ” Practice Location

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