Provider Demographics
NPI:1861754178
Name:GRUBB, BETHANY MARIE (PA)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:MARIE
Last Name:GRUBB
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 VAIL AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1248
Practice Address - Country:US
Practice Address - Phone:704-304-6070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03542363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1861754178Medicaid
SC1841PAMedicaid
NCNC8161BMedicare PIN
NCNC8161CMedicare PIN
NC1861754178Medicaid
SC1841PAMedicaid
NCNC8161FMedicare PIN