Provider Demographics
NPI:1396151395
Name:GRINAGE, JENNIFER (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GRINAGE
Suffix:
Gender:F
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 1:1200 NORA CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:ID
Mailing Address - Zip Code:83871-9647
Mailing Address - Country:US
Mailing Address - Phone:208-792-1011
Mailing Address - Fax:
Practice Address - Street 1:222 SOUTHWAY AVE STE C
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2703
Practice Address - Country:US
Practice Address - Phone:208-792-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA1175363AM0700X
ID1175363A00000X
IDPA-1175363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1396151395Medicaid
ID1396151395Medicaid
WA1396151395Medicaid
WAG8934429Medicare PIN
ID1396151395Medicaid