Provider Demographics
NPI:1689696643
Name:GRABOW, CAROL DEROSA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:DEROSA
Last Name:GRABOW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:FARROCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:108 DORNACH WAY
Mailing Address - Street 2:
Mailing Address - City:ADVANCE
Mailing Address - State:NC
Mailing Address - Zip Code:27006-7305
Mailing Address - Country:US
Mailing Address - Phone:336-940-2407
Mailing Address - Fax:336-940-2409
Practice Address - Street 1:108 DORNACH WAY
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:NC
Practice Address - Zip Code:27006-7305
Practice Address - Country:US
Practice Address - Phone:336-940-2407
Practice Address - Fax:336-940-2409
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102849363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8978751Medicaid
NCMF0498584OtherDEA
NC2753092Medicare ID - Type Unspecified
NCMF0498584OtherDEA