Provider Demographics
NPI:1407107485
Name:GRIMM, LAURA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:GRIMM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:MARIE
Other - Last Name:HAIDET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:929 JASONWAY AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3201
Mailing Address - Country:US
Mailing Address - Phone:614-538-2250
Mailing Address - Fax:614-538-2256
Practice Address - Street 1:929 JASONWAY AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-4321
Practice Address - Country:US
Practice Address - Phone:614-538-2250
Practice Address - Fax:614-538-2256
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0076635Medicaid