Provider Demographics
NPI:1578597480
Name:GROSS, DAVID LAURENCE (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LAURENCE
Last Name:GROSS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3726
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-3726
Mailing Address - Country:US
Mailing Address - Phone:706-863-9595
Mailing Address - Fax:888-745-3917
Practice Address - Street 1:9313 MEDICAL PLAZA DR STE 102
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9153
Practice Address - Country:US
Practice Address - Phone:706-863-9595
Practice Address - Fax:888-745-3917
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCA435363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0083PAMedicare ID - Type Unspecified
S37936Medicare UPIN
SCS379365668Medicare ID - Type Unspecified