Provider Demographics
NPI:1336187301
Name:GRAUSTARK, JORDAN H (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JORDAN
Middle Name:H
Last Name:GRAUSTARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:HELANE
Other - Middle Name:V
Other - Last Name:GRAUSTARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5080 SPECTRUM DR
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4648
Mailing Address - Country:US
Mailing Address - Phone:972-720-7772
Mailing Address - Fax:214-775-4502
Practice Address - Street 1:1 PILLSBURY ST
Practice Address - Street 2:CONCENTRA
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-3556
Practice Address - Country:US
Practice Address - Phone:603-223-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0204P363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30331233Medicaid
NH3081765Medicaid
NHAP1370Medicare PIN
NHR90995Medicare UPIN