Provider Demographics
NPI:1124410444
Name:GRELLO, WILLIAM
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:GRELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:
Other - Last Name:MCMILLAN-GRELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 BREWSTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6000 US-98
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32512-5109
Practice Address - Country:US
Practice Address - Phone:850-505-6601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
TN1123217363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171000000XOther Service ProvidersMilitary Health Care Provider