Basic Information
| Provider Information | |||||||||
| NPI: | 1639273311 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROVE | ||||||||
| FirstName: | DIANE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 N CLARE AVE | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486259194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895394434 | ||||||||
| FaxNumber: | 9895394480 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 N CLARE AVE | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486259194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895394434 | ||||||||
| FaxNumber: | 9895394480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 02/26/2009 | ||||||||
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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 | DG004869 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | DG004869 | 01 | MI | STATE LICENSE | OTHER |