MEDICARE: MR. DAVID KEITH GRIMM FNP

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	363LF0000X	Family Nurse Practitioner	AP3412	AZ

Other Identifiers

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

General Provider Information

NPI Number	:	1699908855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID KEITH GRIMM FNP

Provider Business Mailing Address
First Line	:	PO BOX 245052
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85724-5052
Country	:	US
Telephone Number	:	520-874-2048
Fax Number	:

Provider Business Practice Location Address
First Line	:	3950 S COUNTRY CLUB RD
Second Line	:	SUITE 130
City	:	TUCSON
State	:	AZ
Zip	:	85714-2099
Country	:	US
Telephone Number	:	520-874-2048
Fax Number	:

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

Provider Enumeration Date	:	09/03/2009
Last Update Date	:	07/09/2014

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