MEDICARE: JACOB WESLEY GROSETH DPT

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	363AS0400X	Surgical Physician Assistant	145866	FL
2	208100000X	Physical Medicine & Rehabilitation Physician	PT33205	FL

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	:	1881023539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB WESLEY GROSETH DPT

Provider Business Mailing Address
First Line	:	280 EXEMPLA CIR
Second Line	:
City	:	LAFAYETTE
State	:	CO
Zip	:	80026-3370
Country	:	US
Telephone Number	:	303-338-4545
Fax Number	:

Provider Business Practice Location Address
First Line	:	463688 STATE ROAD 200 STE 9
Second Line	:
City	:	YULEE
State	:	FL
Zip	:	32097-0304
Country	:	US
Telephone Number	:	904-261-4414
Fax Number	:

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

Provider Enumeration Date	:	11/04/2013
Last Update Date	:	12/14/2017

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Directions to “ JACOB WESLEY GROSETH DPT” Practice Location

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