Provider Demographics
NPI:1285734038
Name:GROVER, JEREMY R (PA-C)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:R
Last Name:GROVER
Suffix:
Gender:M
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 1:2918 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-5457
Mailing Address - Country:US
Mailing Address - Phone:970-584-2100
Mailing Address - Fax:970-584-2101
Practice Address - Street 1:2918 W 10TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-5457
Practice Address - Country:US
Practice Address - Phone:970-584-2100
Practice Address - Fax:970-584-2101
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1625363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1625OtherSTATE LISENCE NUMBER
COC462078OtherMEDICARE GROUP