Provider Demographics
NPI:1023043320
Name:GRUENHAGEN, DEANA B (PA)
Entity Type:Individual
Prefix:
First Name:DEANA
Middle Name:B
Last Name:GRUENHAGEN
Suffix:
Gender:F
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:PO BOX 4979
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08754-4979
Mailing Address - Country:US
Mailing Address - Phone:732-244-4700
Mailing Address - Fax:732-244-2804
Practice Address - Street 1:111 WEST WATER STREET
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08754
Practice Address - Country:US
Practice Address - Phone:732-244-4700
Practice Address - Fax:732-244-2804
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011209207P00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6280L21801Medicare PIN
Q71242Medicare UPIN