Provider Demographics
NPI:1710467246
Name:GRIMSHAW, RANDY CLARENCE ANTHONY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:CLARENCE ANTHONY
Last Name:GRIMSHAW
Suffix:
Gender:M
Credentials:PA-C
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:98 MILLER RD APT 101
Mailing Address - Street 2:
Mailing Address - City:RHINEBECK
Mailing Address - State:NY
Mailing Address - Zip Code:12572-3559
Mailing Address - Country:US
Mailing Address - Phone:518-534-4585
Mailing Address - Fax:
Practice Address - Street 1:159 BARNEGAT RD STE 101
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-5402
Practice Address - Country:US
Practice Address - Phone:845-454-1942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY022495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant