Provider Demographics
NPI:1639273311
Name:GROVE, DIANE (PA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:GROVE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 N CLARE AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:MI
Mailing Address - Zip Code:48625-9194
Mailing Address - Country:US
Mailing Address - Phone:989-539-4434
Mailing Address - Fax:989-539-4480
Practice Address - Street 1:815 N CLARE AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:MI
Practice Address - Zip Code:48625-9194
Practice Address - Country:US
Practice Address - Phone:989-539-4434
Practice Address - Fax:989-539-4480
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDG004869363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDG004869OtherSTATE LICENSE
MIM43630030Medicare PIN