Provider Demographics
NPI:1891760427
Name:GROSS, MICHAEL DAVID (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAVID
Last Name:GROSS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:400 AVENUE K, SE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4145
Mailing Address - Country:US
Mailing Address - Phone:863-294-4404
Mailing Address - Fax:863-294-1059
Practice Address - Street 1:400 AVENUE K SE
Practice Address - Street 2:SUITE 11
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4146
Practice Address - Country:US
Practice Address - Phone:863-294-4404
Practice Address - Fax:863-294-1059
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA003304363AM0700X
FLPA9101248363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002229BMedicaid
FL2907941-00Medicaid
FL970021690OtherRAILROAD MEDICARE
GA100002229BMedicaid