Provider Demographics
NPI:1538121835
Name:CONCAUGH-GRUENDEL, JACQUELINE E (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:E
Last Name:CONCAUGH-GRUENDEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 PICCARD DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-4303
Mailing Address - Country:US
Mailing Address - Phone:301-921-7900
Mailing Address - Fax:301-921-7915
Practice Address - Street 1:8700 SUDLEY ROAD
Practice Address - Street 2:PRINCE WILLIAM HOSPITAL
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110
Practice Address - Country:US
Practice Address - Phone:703-369-8337
Practice Address - Fax:703-369-8868
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110001757363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q14056Medicare UPIN
VA004311E54Medicare ID - Type Unspecified