Provider Demographics
NPI:1740321090
Name:GRAM, BROOK ASHLEE (PA-C)
Entity type:Individual
Prefix:
First Name:BROOK
Middle Name:ASHLEE
Last Name:GRAM
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 1:2242 PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-4650
Mailing Address - Country:US
Mailing Address - Phone:330-823-7855
Mailing Address - Fax:
Practice Address - Street 1:18586 5TH ST
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:OH
Practice Address - Zip Code:44609-9799
Practice Address - Country:US
Practice Address - Phone:330-938-3333
Practice Address - Fax:330-938-9375
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2565363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1076079OtherPA CERTIFICATION
OH2565OtherSTATE MEDICAL BOARD