Provider Demographics
NPI:1285419267
Name:GROVE, BREANNE CALLAN (PA-C)
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:CALLAN
Last Name:GROVE
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 1:4755 OGLETOWN STANTON RD STE 1900
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19718-2200
Mailing Address - Country:US
Mailing Address - Phone:302-733-6510
Mailing Address - Fax:302-733-3340
Practice Address - Street 1:4755 OGLETOWN STANTON RD STE 1900
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:302-733-6510
Practice Address - Fax:302-733-3340
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0011968363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant