Provider Demographics
NPI:1538150909
Name:GROSS, PAULINE VIOLA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:PAULINE
Middle Name:VIOLA
Last Name:GROSS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:15699 BEACON CT
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22025-1830
Mailing Address - Country:US
Mailing Address - Phone:703-878-0059
Mailing Address - Fax:703-693-5841
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-539-9582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TX01275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant