Provider Demographics
NPI:1982900866
Name:GROSSMAN, JENNA (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:GROSSMAN
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 1:200 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5884
Mailing Address - Country:US
Mailing Address - Phone:410-768-5555
Mailing Address - Fax:410-799-1441
Practice Address - Street 1:200 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5884
Practice Address - Country:US
Practice Address - Phone:410-768-5555
Practice Address - Fax:410-799-1441
Is Sole Proprietor?:No
Enumeration Date:2011-02-10
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004382363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD349420YWV2Medicare PIN
MD349458ZDDBMedicare PIN
MD349458YVZMedicare PIN