Provider Demographics
NPI:1821225194
Name:GROSS, VANTREIA M (PA-C)
Entity type:Individual
Prefix:MS
First Name:VANTREIA
Middle Name:M
Last Name:GROSS
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 1:110 PATRICK CT
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-1743
Mailing Address - Country:US
Mailing Address - Phone:252-443-0400
Mailing Address - Fax:252-443-0572
Practice Address - Street 1:110 PATRICK CT
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804
Practice Address - Country:US
Practice Address - Phone:252-443-0400
Practice Address - Fax:252-443-0572
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003966363A00000X
NC0010-07471363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNN1677AOtherMEDICARE
MDK858Medicare PIN
MD195448Y3PMedicare PIN