Basic Information
| Provider Information | |||||||||
| NPI: | 1891769485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROME | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ARNOLD | ||||||||
| OtherFirstName: | REGINA | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4190 | ||||||||
| Address2: | |||||||||
| City: | BARBOURSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255044190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043994405 | ||||||||
| FaxNumber: | 3043992526 | ||||||||
| Practice Location | |||||||||
| Address1: | 143 PEYTON STREET | ||||||||
| Address2: | |||||||||
| City: | BARBOURSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046972035 | ||||||||
| FaxNumber: | 3045231485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 04/09/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 00291 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3810000471 | 05 | WV | MEDICAID | 001719144 | 01 | MS BC/BS | OTHER | 110117516 | 01 | RR MEDICARE | OTHER |