Provider Demographics
NPI:1821714106
Name:GRONVOLD, GRACE ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:ELIZABETH
Last Name:GRONVOLD
Suffix:
Gender:F
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 1:3009 NEW BERN AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1214
Mailing Address - Country:US
Mailing Address - Phone:919-232-5020
Mailing Address - Fax:
Practice Address - Street 1:3009 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1214
Practice Address - Country:US
Practice Address - Phone:919-232-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12790363A00000X
363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1821714106Medicaid