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NPI Code Detail

MEDICARE: GRACE WEST PA

MEDICARE: GRACE WEST 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
1363A00000XPhysician AssistantPA-1475AR

General Provider Information

NPI Number : 1932086576
Entity Type Code : Individual
Provider Name (Legal Business Name) : GRACE WEST PA
Provider Business Mailing Address
First Line : PO BOX 776084
Second Line :
City : CHICAGO
State : IL
Zip : 60677-6084
Country : US
Telephone Number : 479-314-6245
Fax Number : 479-452-0275
Provider Business Practice Location Address
First Line : 7301 ROGERS AVE
Second Line :
City : FORT SMITH
State : AR
Zip : 72903-4100
Country : US
Telephone Number : 479-314-6245
Fax Number : 479-452-0275
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/18/2025
Last Update Date : 03/02/2026

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Directions to “ GRACE WEST PA” Practice Location

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