Provider Demographics
NPI:1245636737
Name:GRELL, ALEXANDER (PA-C)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:GRELL
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 1:6767 W 29TH STREET
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-5474
Mailing Address - Country:US
Mailing Address - Phone:970-652-2433
Mailing Address - Fax:970-652-2252
Practice Address - Street 1:6767 WEST 29TH STREET
Practice Address - Street 2:2ND FLOOR
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634
Practice Address - Country:US
Practice Address - Phone:970-652-2433
Practice Address - Fax:970-652-2252
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4167363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO76103510Medicaid