Provider Demographics
NPI:1083623441
Name:GROVER, GARY (ACNP)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:GROVER
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 W POPLAR AVE
Mailing Address - Street 2:SUITE 312
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-0601
Mailing Address - Country:US
Mailing Address - Phone:901-850-1170
Mailing Address - Fax:901-850-1169
Practice Address - Street 1:6025 WALNUT GROVE RD
Practice Address - Street 2:SUITE 508
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2131
Practice Address - Country:US
Practice Address - Phone:901-767-5864
Practice Address - Fax:901-767-6591
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6785363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3349528Medicare ID - Type Unspecified
TNP95530Medicare UPIN