Provider Demographics
NPI:1790930527
Name:GRONBERG, WILLIAM CHARLES (PA-C)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CHARLES
Last Name:GRONBERG
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 1:222 W THOMAS RD STE 307
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4422
Mailing Address - Country:US
Mailing Address - Phone:602-406-8811
Mailing Address - Fax:602-406-8811
Practice Address - Street 1:222 W THOMAS RD STE 307
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4422
Practice Address - Country:US
Practice Address - Phone:602-406-8811
Practice Address - Fax:602-406-8811
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2021-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4914207X00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ147419Medicare PIN