Provider Demographics
NPI:1407110653
Name:GRIMM, ADAM C (PA)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:C
Last Name:GRIMM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N15W28300 GOLF RD
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-4800
Mailing Address - Country:US
Mailing Address - Phone:262-303-5055
Mailing Address - Fax:262-303-5057
Practice Address - Street 1:N15W28300 GOLF RD
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-4800
Practice Address - Country:US
Practice Address - Phone:262-303-5055
Practice Address - Fax:262-303-5057
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100887-875363A00000X
WI7534363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100046348Medicaid
MN970006273Medicare PIN