Provider Demographics
NPI:1730897703
Name:GROTHAUS, COLLIN (AGACNP, CNP)
Entity type:Individual
Prefix:
First Name:COLLIN
Middle Name:
Last Name:GROTHAUS
Suffix:
Gender:M
Credentials:AGACNP, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 TAFT ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:45830-1122
Mailing Address - Country:US
Mailing Address - Phone:567-204-4499
Mailing Address - Fax:
Practice Address - Street 1:630 E RIVER ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-5902
Practice Address - Country:US
Practice Address - Phone:440-329-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0032129363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care