Provider Demographics
NPI:1841713195
Name:DEGROOT, JAMES
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:DEGROOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4683 OMAHA BEACH ST
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-1914
Mailing Address - Country:US
Mailing Address - Phone:480-200-0284
Mailing Address - Fax:
Practice Address - Street 1:WEED ARMY COMMUNITY HOSPITAL 390 NORTH LOOP RD.
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:760-383-5053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN172301163WC0200X
390200000X
WAAP60981185367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program