Provider Demographics
NPI:1710955372
Name:GRAM HUMPHREY, NINA ELISABETH (PA-C, MPA)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:ELISABETH
Last Name:GRAM HUMPHREY
Suffix:
Gender:F
Credentials:PA-C, MPA
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:ELIZABETH
Other - Last Name:GRAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C, MPA
Mailing Address - Street 1:320 E NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-4756
Mailing Address - Country:US
Mailing Address - Phone:412-330-1818
Mailing Address - Fax:
Practice Address - Street 1:320 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-4756
Practice Address - Country:US
Practice Address - Phone:412-330-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052452363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1069736OtherNCCPA CERT NO.