Provider Demographics
NPI:1790087187
Name:GROSE, BERNARD DEAN II (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:DEAN
Last Name:GROSE
Suffix:II
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 KANAWHA TER
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-2750
Mailing Address - Country:US
Mailing Address - Phone:304-201-1130
Mailing Address - Fax:304-201-1134
Practice Address - Street 1:12 KANAWHA TER
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-2750
Practice Address - Country:US
Practice Address - Phone:304-201-1130
Practice Address - Fax:304-201-1134
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01522363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1790087187Medicaid
WVWV1245BOtherMEDICARE PTAN
WV3810019933Medicaid
WVWV1245COtherMEDICARE PTAN