Provider Demographics
NPI:1023203569
Name:OSBORNE, ELLEN GRIMES (PA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:GRIMES
Last Name:OSBORNE
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 1:8835 VANS ST
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-4656
Mailing Address - Country:US
Mailing Address - Phone:562-633-5111
Mailing Address - Fax:
Practice Address - Street 1:8835 VANS ST
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-4656
Practice Address - Country:US
Practice Address - Phone:562-633-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12484363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant