Basic Information
| Provider Information | |||||||||
| NPI: | 1174998918 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRACE | ||||||||
| FirstName: | JEFFREY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | BASSETT ARMY MEDICAL CENTER | ||||||||
| Address2: | 1060 GAFFNEY RD | ||||||||
| City: | FT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073615603 | ||||||||
| FaxNumber: | 9073614847 | ||||||||
| Practice Location | |||||||||
| Address1: | BASSETT ARMY MEDICAL CENTER (KAMISH CLINIC) | ||||||||
| Address2: | 1060 GAFFNEY RD | ||||||||
| City: | FT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073534127 | ||||||||
| FaxNumber: | 9073614847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2015 | ||||||||
| LastUpdateDate: | 11/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.