Basic Information
| Provider Information | |||||||||
| NPI: | 1730589185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRUNOW | ||||||||
| FirstName: | CHANEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HIBERD | ||||||||
| OtherFirstName: | CHANEY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 800 W MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177597000 | ||||||||
| FaxNumber: | 8178828053 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 W MAYFIELD RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760142083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173333300 | ||||||||
| FaxNumber: | 8177597027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2014 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 345147801 | 05 | TX | MEDICAID | 345147802 | 05 | TX | MEDICAID | 8493NN | 01 | BCBS | OTHER |