Provider Demographics
NPI:1740659762
Name:GRIMES, JOHN VANLOON (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:VANLOON
Last Name:GRIMES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:1800 MULBERRY ST
Practice Address - Street 2:M. C. 68-74
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-6800
Practice Address - Country:US
Practice Address - Phone:570-703-7245
Practice Address - Fax:570-703-7325
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057958363AS0400X, 363A00000X
PAOA003665363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA466481OtherMEDICARE