Basic Information
Provider Information | |||||||||
NPI: | 1366446304 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VAN GRINSVEN | ||||||||
FirstName: | LAURIE | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1440 | ||||||||
Address2: |   | ||||||||
City: | WAUTOMA | ||||||||
State: | WI | ||||||||
PostalCode: | 549821440 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9207875514 | ||||||||
FaxNumber: | 9207874737 | ||||||||
Practice Location | |||||||||
Address1: | 400 S TOWNLINE RD | ||||||||
Address2: |   | ||||||||
City: | WAUTOMA | ||||||||
State: | WI | ||||||||
PostalCode: | 54982 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9207875514 | ||||||||
FaxNumber: | 9207874737 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2005 | ||||||||
LastUpdateDate: | 08/20/2018 | ||||||||
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 | 363AM0700X | 938-023 | WI | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 938-023 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 521823 | 01 | WI | MEDICARE PART A - CLINIC | OTHER | 41971000 | 05 | WI |   | MEDICAID | 521824 | 01 | WI | MEDICARE A MOBIL UNIT | OTHER |