Provider Demographics
NPI:1891769485
Name:GROME, REGINA D (PA-C)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:D
Last Name:GROME
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:D
Other - Last Name:ARNOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 4190
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-4190
Mailing Address - Country:US
Mailing Address - Phone:304-399-4405
Mailing Address - Fax:304-399-2526
Practice Address - Street 1:143 PEYTON STREET
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504
Practice Address - Country:US
Practice Address - Phone:304-697-2035
Practice Address - Fax:304-523-1485
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00291363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000471Medicaid
001719144OtherMS BC/BS
110117516OtherRR MEDICARE