Provider Demographics
NPI:1164601977
Name:SHERMAN GRODA, DEBORAH LYNN (PAC)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LYNN
Last Name:SHERMAN GRODA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 SQUALICUM WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2076
Mailing Address - Country:US
Mailing Address - Phone:360-676-1470
Mailing Address - Fax:360-676-0377
Practice Address - Street 1:905 SQUALICUM WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2076
Practice Address - Country:US
Practice Address - Phone:360-676-1470
Practice Address - Fax:360-676-0377
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60521708363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A10115OtherBCBSM GROUP
MI5601004851OtherSTATE LICENSE
MICG9582OtherPALMETTO GBA GROUP
MI1538192018OtherGROUP NPI
MIN90850007Medicare PIN
MICG9582OtherPALMETTO GBA GROUP