Basic Information
| Provider Information | |||||||||
| NPI: | 1578881082 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIMES | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | MCCUAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4315 JAMES CASEY ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787453365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124447944 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4315 JAMES CASEY ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787453365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124447944 | ||||||||
| FaxNumber: | 5124447946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2010 | ||||||||
| LastUpdateDate: | 09/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA06528 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 328317803 | 05 | TX | MEDICAID | 328317804 | 05 | TX | MEDICAID | PA06528 | 01 | TX | TEXAS STATE LICENSE | OTHER |