Provider Demographics
NPI:1548598733
Name:GROVER, JONATHAN DANIEL (BSN)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:DANIEL
Last Name:GROVER
Suffix:
Gender:M
Credentials:BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7027
Mailing Address - Country:US
Mailing Address - Phone:207-795-0111
Mailing Address - Fax:207-795-5653
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7027
Practice Address - Country:US
Practice Address - Phone:207-795-0111
Practice Address - Fax:207-795-5653
Is Sole Proprietor?:No
Enumeration Date:2009-11-26
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAA103003367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME001678601Medicare PIN