Provider Demographics
NPI:1003932476
Name:GROGAN, JAMES ALAN (PA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ALAN
Last Name:GROGAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5730 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48450-8800
Mailing Address - Country:US
Mailing Address - Phone:810-696-2088
Mailing Address - Fax:810-696-2088
Practice Address - Street 1:5730 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MI
Practice Address - Zip Code:48450-8800
Practice Address - Country:US
Practice Address - Phone:810-696-2088
Practice Address - Fax:810-696-2088
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001722363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382516038OtherGROUP PRACTICE TAX ID NUM
MI0F34972Medicare PIN
MI382516038OtherGROUP PRACTICE TAX ID NUM