Provider Demographics
NPI:1659175834
Name:GRIST, ANGELICA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:ROSE
Last Name:GRIST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3536 WRIGHT RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-4430
Mailing Address - Country:US
Mailing Address - Phone:828-301-8565
Mailing Address - Fax:
Practice Address - Street 1:1211 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-0004
Practice Address - Country:US
Practice Address - Phone:615-322-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-04
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6520363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant