Provider Demographics
NPI:1073522215
Name:GRENKE, ALAN J (PA)
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:J
Last Name:GRENKE
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 1:2826 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-5209
Mailing Address - Country:US
Mailing Address - Phone:520-393-8234
Mailing Address - Fax:
Practice Address - Street 1:2800 E AJO WAY
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-6204
Practice Address - Country:US
Practice Address - Phone:520-874-4921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-854363A00000X
AZ3748363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ121868Medicaid
AZ329420OtherSTATE AHCCCS
AZ329420OtherSTATE AHCCCS