Provider Demographics
NPI:1912253576
Name:GROSVELD, SUSETTE (PA-C)
Entity type:Individual
Prefix:
First Name:SUSETTE
Middle Name:
Last Name:GROSVELD
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 1:12291 WASHINGTON BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90606-2549
Mailing Address - Country:US
Mailing Address - Phone:562-698-0306
Mailing Address - Fax:
Practice Address - Street 1:12291 WASHINGTON BLVD STE 201
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90606-2549
Practice Address - Country:US
Practice Address - Phone:562-698-0306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant