Provider Demographics
NPI:1700973583
Name:GROVE, CALEB W (PA)
Entity Type:Individual
Prefix:MR
First Name:CALEB
Middle Name:W
Last Name:GROVE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:720 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042-2112
Mailing Address - Country:US
Mailing Address - Phone:316-322-2490
Mailing Address - Fax:316-321-2916
Practice Address - Street 1:700 W CENTRAL AVE STE 105
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2187
Practice Address - Country:US
Practice Address - Phone:316-322-9813
Practice Address - Fax:316-322-9806
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KST00782363AM0700X
KS15-01144363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0000427308OtherBLUE CROSS BLUE SHIELD
KS200406070DMedicaid
KS0000427308OtherBLUE CROSS BLUE SHIELD