Basic Information
Provider Information | |||||||||
NPI: | 1336187301 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAUSTARK | ||||||||
FirstName: | JORDAN | ||||||||
MiddleName: | H | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRAUSTARK | ||||||||
OtherFirstName: | HELANE | ||||||||
OtherMiddleName: | V | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5080 SPECTRUM DR | ||||||||
Address2: |   | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 750014648 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9727207772 | ||||||||
FaxNumber: | 2147754502 | ||||||||
Practice Location | |||||||||
Address1: | 1 PILLSBURY ST | ||||||||
Address2: | CONCENTRA | ||||||||
City: | CONCORD | ||||||||
State: | NH | ||||||||
PostalCode: | 033013556 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6032232300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/03/2006 | ||||||||
LastUpdateDate: | 08/06/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0204P | NH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 30331233 | 05 | NH |   | MEDICAID | 3081765 | 05 | NH |   | MEDICAID |