Provider Demographics
NPI:1154318574
Name:GRIMM, PATRICK J (PA-C)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:J
Last Name:GRIMM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2338
Mailing Address - Country:US
Mailing Address - Phone:406-375-4823
Mailing Address - Fax:406-375-4846
Practice Address - Street 1:1200 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2345
Practice Address - Country:US
Practice Address - Phone:406-363-0597
Practice Address - Fax:406-375-4858
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT468363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1154318574Medicaid
MT1154318574Medicaid
MTM011001769 BPCMedicare PIN
MTM011001768Medicare Oscar/Certification
MTM011001770 CFMMedicare PIN
MTM011001767 MDMHMedicare PIN