Provider Demographics
NPI:1477781557
Name:GRONOSTAJSKI, REID EDWARD (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:REID
Middle Name:EDWARD
Last Name:GRONOSTAJSKI
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3219 SCRIMSHAW CT
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-6258
Mailing Address - Country:US
Mailing Address - Phone:609-977-5466
Mailing Address - Fax:
Practice Address - Street 1:1140 ROUTE 72 W
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2412
Practice Address - Country:US
Practice Address - Phone:609-978-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054369363AM0700X
NJ25MP00218400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical