Provider Demographics
NPI:1366484354
Name:GRUBB, CHARLES MACK (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MACK
Last Name:GRUBB
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:5501 INDEPENDENCE PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75023-5463
Mailing Address - Country:US
Mailing Address - Phone:972-596-1747
Mailing Address - Fax:972-985-9775
Practice Address - Street 1:5501 INDEPENDENCE PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75023-5463
Practice Address - Country:US
Practice Address - Phone:972-596-1747
Practice Address - Fax:972-985-9775
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA03541363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84P07Medicare PIN
TXP69621Medicare UPIN