Provider Demographics
NPI:1396815015
Name:GRIMES, MICHAEL DANA
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DANA
Last Name:GRIMES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:DANA
Other - Last Name:GRIMES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2828 1ST AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1236
Mailing Address - Country:US
Mailing Address - Phone:304-525-6905
Mailing Address - Fax:304-525-4316
Practice Address - Street 1:2828 1ST AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1236
Practice Address - Country:US
Practice Address - Phone:304-525-6905
Practice Address - Fax:304-525-4316
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV905363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV905OtherSTATE LICENSE
WV381000527Medicaid
WV381000527Medicaid
GRPA20671Medicare ID - Type Unspecified
WV381000527Medicaid