Provider Demographics
NPI:1689393654
Name:GROVER, KENNETH JUSTIN (PA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JUSTIN
Last Name:GROVER
Suffix:
Gender:M
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:PO BOX 1616
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-0018
Mailing Address - Country:US
Mailing Address - Phone:800-672-7210
Mailing Address - Fax:541-758-3713
Practice Address - Street 1:620 W HAYS ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5511
Practice Address - Country:US
Practice Address - Phone:208-381-2094
Practice Address - Fax:208-381-1791
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program