Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 1588 | AZ |
Y | 213ES0000X | Sports Medicine | 1588 | AZ |
NPI | 1306333182 |
---|---|
Provider Name | Gavin Grosh |
First Address | Surprise, AZ 85374-8844 |
Second Address | Surprise, AZ 85374-8844 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/04/2018 |
Last Update Date | 17/04/2018 |