Provider Demographics
NPI:1558640011
Name:GRULLON, DALERY (PA-C)
Entity Type:Individual
Prefix:
First Name:DALERY
Middle Name:
Last Name:GRULLON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-5030
Mailing Address - Fax:215-707-3494
Practice Address - Street 1:540 N DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2374
Practice Address - Country:US
Practice Address - Phone:717-544-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-15
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014920363A00000X
PAMA058779363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY014920OtherLICENSE