Basic Information
| Provider Information | |||||||||
| NPI: | 1881023539 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROSETH | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | WESLEY | ||||||||
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| Credential: | DPT | ||||||||
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| OtherLastName: | GROSETH | ||||||||
| OtherFirstName: | JAKE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 280 EXEMPLA CIR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800263370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033384545 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 463688 STATE ROAD 200 STE 9 | ||||||||
| Address2: | |||||||||
| City: | YULEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320970304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042614414 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2013 | ||||||||
| LastUpdateDate: | 12/14/2017 | ||||||||
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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 | 363AS0400X | 145866 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 208100000X | PT33205 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.