Provider Demographics
NPI:1891026795
Name:GROELLER, ASHLEY M (PAC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:M
Last Name:GROELLER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:M
Other - Last Name:SCHRADER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DRIVE
Mailing Address - Street 2:MAILBOX 117
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:260-266-8210
Mailing Address - Fax:
Practice Address - Street 1:3909 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1725
Practice Address - Country:US
Practice Address - Phone:260-469-6610
Practice Address - Fax:260-969-3065
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-18
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT36064363A00000X
IN10001390A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant