Individual
LAURIE A VAN GRINSVEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
400 S TOWNLINE RD, WAUTOMA, WI 54982
(920) 787-5514
(920) 787-4737
Mailing address
PO BOX 1440, WAUTOMA, WI 54982-1440
(920) 787-5514
(920) 787-4737
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
938-023
WI
363AM0700X
Medical Physician Assistant
938-023
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
41971000
—
WI
01
—
521823
MEDICARE PART A - CLINIC
WI
01
—
521824
MEDICARE A MOBIL UNIT
WI
Enumeration date
06/08/2005
Last updated
08/20/2018
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