Provider Demographics
NPI:1104023381
Name:GRIMM, NICHOLAS P (PA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:P
Last Name:GRIMM
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:3515 MURRAY ST
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3367
Practice Address - Country:US
Practice Address - Phone:715-732-0699
Practice Address - Fax:715-732-3522
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2166-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2166-023OtherSTATE LICENSE
WI2166-023OtherSTATE LICENSE
WI2166-023OtherSTATE LICENSE
WI41938900Medicaid
WIMG1643863OtherDEA