Provider Demographics
NPI:1629708532
Name:GROGAN, KYLIE JO (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:JO
Last Name:GROGAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:JO
Other - Last Name:PASTIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4440 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-7245
Mailing Address - Country:US
Mailing Address - Phone:701-732-7700
Mailing Address - Fax:
Practice Address - Street 1:4440 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-7245
Practice Address - Country:US
Practice Address - Phone:701-732-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0954363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant