MEDICARE: MR. BRECK GROSKREUTZ 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	PT893	WY
2	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	PA893	WY

General Provider Information

NPI Number	:	1972130565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRECK GROSKREUTZ PA

Provider Business Mailing Address
First Line	:	234 E 1ST ST
Second Line	:
City	:	CASPER
State	:	WY
Zip	:	82601-2516
Country	:	US
Telephone Number	:	307-315-6403
Fax Number	:	833-992-2034

Provider Business Practice Location Address
First Line	:	234 E 1ST ST
Second Line	:
City	:	CASPER
State	:	WY
Zip	:	82601-2516
Country	:	US
Telephone Number	:	307-315-6403
Fax Number	:	833-992-2034

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

Provider Enumeration Date	:	03/24/2020
Last Update Date	:	12/13/2024

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