Provider Demographics
NPI:1891733267
Name:GRIMONE, COLLEEN M (PA-C)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:GRIMONE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:M
Other - Last Name:BIRKEMEIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 PEACH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1423
Mailing Address - Country:US
Mailing Address - Phone:814-456-7733
Mailing Address - Fax:814-456-7213
Practice Address - Street 1:100 PEACH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1423
Practice Address - Country:US
Practice Address - Phone:814-456-7733
Practice Address - Fax:814-456-7213
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051836363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102457Medicare PIN
Q52587Medicare UPIN