Provider Demographics
NPI:1972130565
Name:GROSKREUTZ, BRECK (PA)
Entity Type:Individual
Prefix:MR
First Name:BRECK
Middle Name:
Last Name:GROSKREUTZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 WILKINS CIR
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-1337
Mailing Address - Country:US
Mailing Address - Phone:307-233-2700
Mailing Address - Fax:307-472-2883
Practice Address - Street 1:1441 WILKINS CIR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-1337
Practice Address - Country:US
Practice Address - Phone:307-233-2700
Practice Address - Fax:307-472-2883
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT893363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant