Provider Demographics
NPI:1992130207
Name:EUSTICE, GRACE JENNIFER (PA-C)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:JENNIFER
Last Name:EUSTICE
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 1:5612 EASTON ROAD
Mailing Address - Street 2:P.O.BOX 866
Mailing Address - City:PLUMSTEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18949-0866
Mailing Address - Country:US
Mailing Address - Phone:215-766-8844
Mailing Address - Fax:
Practice Address - Street 1:5612 EASTON ROAD
Practice Address - Street 2:
Practice Address - City:PLUMSTEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:18949-0866
Practice Address - Country:US
Practice Address - Phone:215-766-8844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056310363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant