Provider Demographics
NPI:1114963691
Name:GRIMSLEY, MAHLON DAVID (PA)
Entity Type:Individual
Prefix:MR
First Name:MAHLON
Middle Name:DAVID
Last Name:GRIMSLEY
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 1:4415 ANGIER AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-5803
Mailing Address - Country:US
Mailing Address - Phone:919-957-7862
Mailing Address - Fax:
Practice Address - Street 1:1824 HILLANDALE RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2650
Practice Address - Country:US
Practice Address - Phone:919-957-7862
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1021201OtherNCCPA #