Provider Demographics
NPI:1790828119
Name:GRINNELL, TIMOTHY D (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:D
Last Name:GRINNELL
Suffix:
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 1:110 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5521
Mailing Address - Country:US
Mailing Address - Phone:508-565-3055
Mailing Address - Fax:508-894-0757
Practice Address - Street 1:110 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5521
Practice Address - Country:US
Practice Address - Phone:508-565-3055
Practice Address - Fax:508-894-0757
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAP2274363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical