Provider Demographics
NPI:1417227075
Name:GROVIJOHN, REBA ANN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:REBA
Middle Name:ANN
Last Name:GROVIJOHN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:REBA
Other - Middle Name:ANN
Other - Last Name:CRAIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2301 S CLEAR CREEK RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-4143
Mailing Address - Country:US
Mailing Address - Phone:254-628-5454
Mailing Address - Fax:
Practice Address - Street 1:2301 S CLEAR CREEK RD
Practice Address - Street 2:SUITE 206
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4143
Practice Address - Country:US
Practice Address - Phone:254-628-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07492363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant