Provider Demographics
NPI:1124410444
Name:GRELLO, WILLIAM (PA-C)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:GRELLO
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:
Other - Last Name:MCMILLAN-GRELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 BREWSTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2575
Practice Address - Country:US
Practice Address - Phone:910-450-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5788363A00000X
TN1123217363A00000X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant