Provider Demographics
NPI:1467420695
Name:GRODELL, PATRICE CATHRYN (PA)
Entity Type:Individual
Prefix:MS
First Name:PATRICE
Middle Name:CATHRYN
Last Name:GRODELL
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:UFJP NEONATOLOGY DEPT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-5100
Practice Address - Fax:904-244-6658
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2007-12-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9101089363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE2951ZMedicare PIN
FLS87550Medicare UPIN