Basic Information
| Provider Information | |||||||||
| NPI: | 1891209870 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIGG | ||||||||
| FirstName: | CARLIE | ||||||||
| MiddleName: | ALEXANDRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 495 SW RAMSEY AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414766644 | ||||||||
| FaxNumber: | 5414725673 | ||||||||
| Practice Location | |||||||||
| Address1: | 1524 NORMANDY VILLAGE PKWY | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322217690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044821400 | ||||||||
| FaxNumber: | 9044821402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2017 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA185615 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA9113179 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.