Provider Demographics
NPI:1104886829
Name:GROSSINGER, SAMUEL M (PA)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:M
Last Name:GROSSINGER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 15386
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-0386
Mailing Address - Country:US
Mailing Address - Phone:919-477-5152
Mailing Address - Fax:919-477-5474
Practice Address - Street 1:3643 N ROXBORO ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2702
Practice Address - Country:US
Practice Address - Phone:919-477-5152
Practice Address - Fax:919-477-5474
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC101391363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2743372Medicare PIN
NCS39507Medicare UPIN