Provider Demographics
NPI:1568198224
Name:GRINNELL, NICHOLAS JOSEPH (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:GRINNELL
Suffix:
Gender:M
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 1:81 STREIT RD
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-7553
Mailing Address - Country:US
Mailing Address - Phone:360-461-1133
Mailing Address - Fax:
Practice Address - Street 1:808 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3045
Practice Address - Country:US
Practice Address - Phone:360-683-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61309930363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA61309930OtherPROVIDER CREDENTIAL NUMBER