Provider Demographics
NPI:1104229699
Name:GRIM, CARYN R (PA)
Entity type:Individual
Prefix:
First Name:CARYN
Middle Name:R
Last Name:GRIM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARYN
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3480 YORKSHIRE MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1886
Mailing Address - Country:US
Mailing Address - Phone:859-263-5140
Mailing Address - Fax:859-263-5141
Practice Address - Street 1:1350 FLEMINGSBURG RD
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1810
Practice Address - Country:US
Practice Address - Phone:859-263-5140
Practice Address - Fax:859-263-5141
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC294363AS0400X
KYPA1923363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100396660Medicaid
KYPA1923OtherSTATE LICENSE