Provider Demographics
NPI:1891199022
Name:GRANDMAISON, KRISTEN (PA)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:
Last Name:GRANDMAISON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 MORRIS AVE
Mailing Address - Street 2:SUITE A-109
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-5714
Mailing Address - Country:US
Mailing Address - Phone:908-964-8550
Mailing Address - Fax:908-964-6307
Practice Address - Street 1:2333 MORRIS AVE
Practice Address - Street 2:SUITE A-109
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-5714
Practice Address - Country:US
Practice Address - Phone:908-964-8550
Practice Address - Fax:908-964-6307
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00348000363A00000X
NY006229363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant