MEDICARE: MEGAN DIANE GROSSMAN PA

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	PA55954	CA

General Provider Information

NPI Number	:	1376027235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEGAN DIANE GROSSMAN PA

Provider Business Mailing Address
First Line	:	1125 E BROADWAY
Second Line	:	BOX 71
City	:	GLENDALE
State	:	CA
Zip	:	91205-1315
Country	:	US
Telephone Number	:	818-790-1088
Fax Number	:	818-790-1778

Provider Business Practice Location Address
First Line	:	2438 N PONDEROSA DR STE C105
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93010-2465
Country	:	US
Telephone Number	:	805-388-2068
Fax Number	:	805-484-7700

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

Provider Enumeration Date	:	09/18/2018
Last Update Date	:	07/25/2025

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Directions to “ MEGAN DIANE GROSSMAN PA” Practice Location

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