Provider Demographics
NPI:1578881082
Name:GRIMES, MICHELLE MCCUAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MCCUAN
Last Name:GRIMES
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 1:4315 JAMES CASEY ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-3365
Mailing Address - Country:US
Mailing Address - Phone:512-444-7944
Mailing Address - Fax:
Practice Address - Street 1:4315 JAMES CASEY ST
Practice Address - Street 2:SUITE 300
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-3365
Practice Address - Country:US
Practice Address - Phone:512-444-7944
Practice Address - Fax:512-444-7946
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328317803Medicaid
TX328317804Medicaid
TXPA06528OtherTEXAS STATE LICENSE
TXPA06528OtherTEXAS STATE LICENSE
TX418056YVKLMedicare PIN