Provider Demographics
NPI:1912960659
Name:GRISSOM, JERALD DEAN JR (PA-C)
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:DEAN
Last Name:GRISSOM
Suffix:JR
Gender:M
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 1:2271 N NC 119
Mailing Address - Street 2:
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302
Mailing Address - Country:US
Mailing Address - Phone:336-380-7277
Mailing Address - Fax:336-716-7277
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-8898
Practice Address - Fax:336-716-7277
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04281363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant