Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 0401005512 | VA |
Y | 213EG0000X | General Practice | 0401005512 | VA |
NPI | 1003095266 |
---|---|
Provider Name | Dr. Bryan L Grimmer |
First Address | Herndon, VA 20170-4868 |
Second Address | Herndon, VA 20170-4868 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/10/2007 |
Last Update Date | 24/10/2007 |