MEDICARE: LAURIE A VAN GRINSVEN 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	363AM0700X	Medical Physician Assistant	938-023	WI
2	363A00000X	Physician Assistant	938-023	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	521823	OTHER	WI	MEDICARE PART A - CLINIC
3	521824	OTHER	WI	MEDICARE A MOBIL UNIT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366446304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURIE A VAN GRINSVEN PA-C

Provider Business Mailing Address
First Line	:	PO BOX 1440
Second Line	:
City	:	WAUTOMA
State	:	WI
Zip	:	54982-1440
Country	:	US
Telephone Number	:	920-787-5514
Fax Number	:	920-787-4737

Provider Business Practice Location Address
First Line	:	400 S TOWNLINE RD
Second Line	:
City	:	WAUTOMA
State	:	WI
Zip	:	54982
Country	:	US
Telephone Number	:	920-787-5514
Fax Number	:	920-787-4737

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

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	08/20/2018

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Directions to “ LAURIE A VAN GRINSVEN PA-C” Practice Location

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