Provider Demographics
NPI:1053445866
Name:GRISSETT, TASHA (PA)
Entity Type:Individual
Prefix:MISS
First Name:TASHA
Middle Name:
Last Name:GRISSETT
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 1:8430 W RILEY RD
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-3683
Mailing Address - Country:US
Mailing Address - Phone:623-478-5280
Mailing Address - Fax:
Practice Address - Street 1:14502 W MEEKER BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5282
Practice Address - Country:US
Practice Address - Phone:623-524-8767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00285363A00000X
GA005537363A00000X
AZ5752363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPENDINGMedicaid
NCPENDINGMedicare UPIN
NCPENDINGMedicare ID - Type UnspecifiedPROVIDER NUMBER