Provider Demographics
NPI:1427144997
Name:GRIMBALL, ANDREA TOMASEK (PA-C)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:TOMASEK
Last Name:GRIMBALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:DAWN
Other - Last Name:TOMASEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:27 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3949
Mailing Address - Country:US
Mailing Address - Phone:731-424-1001
Mailing Address - Fax:
Practice Address - Street 1:27 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3949
Practice Address - Country:US
Practice Address - Phone:731-424-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101918363A00000X
TNPA0000001561363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL059051687OtherBCBS OF ALABAMA
970023893OtherRAILROAD MEDICARE
FL291182500Medicaid
AL009976550Medicaid
FLE6913ZMedicare PIN
AL009976550Medicaid