Provider Demographics
NPI:1245516459
Name:SYMENOW, GREGORY (PA-C)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:SYMENOW
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12025 SHORTLEAF LN
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23146-1859
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3550 PINE GROVE AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-1944
Practice Address - Country:US
Practice Address - Phone:833-620-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10218363A00000X
MI5601010944363A00000X
IL085.008777363A00000X
NY027730363A00000X
OH50.007382363A00000X
VA0110003771363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant