Provider Demographics
NPI:1912397225
Name:GRODE, NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GRODE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:NEUBAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7169 KALAMAZOO AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-8146
Mailing Address - Country:US
Mailing Address - Phone:616-266-9100
Mailing Address - Fax:616-266-9200
Practice Address - Street 1:7169 KALAMAZOO AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316
Practice Address - Country:US
Practice Address - Phone:616-266-9100
Practice Address - Fax:616-266-9200
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M28750Medicare PIN