Provider Demographics
NPI:1467197723
Name:GROSRENAUD, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:GROSRENAUD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 ZONAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-5601
Mailing Address - Country:US
Mailing Address - Phone:847-347-9120
Mailing Address - Fax:
Practice Address - Street 1:1975 ZONAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-5601
Practice Address - Country:US
Practice Address - Phone:847-347-9120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program