Provider Demographics
NPI:1366484354
Name:GRUBB, CHARLES MACK (PA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MACK
Last Name:GRUBB
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6750 N MACARTHUR BLVD STE 350
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-2484
Mailing Address - Country:US
Mailing Address - Phone:972-556-1616
Mailing Address - Fax:972-556-1740
Practice Address - Street 1:6750 N MACARTHUR BLVD STE 350
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-2484
Practice Address - Country:US
Practice Address - Phone:972-556-1616
Practice Address - Fax:972-556-1740
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03541363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84P07Medicare PIN
TXP69621Medicare UPIN