Provider Demographics
NPI:1437479458
Name:GONGIDI, GRACE K (PA)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:K
Last Name:GONGIDI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:K
Other - Last Name:CROTZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1860
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-7840
Practice Address - Fax:682-885-7856
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX218484801Medicaid
TXB116686Medicare PIN