Basic Information
| Provider Information | |||||||||
| NPI: | 1902331564 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROGG | ||||||||
| FirstName: | BETHANY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7147 VISTA DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | WEST DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502669313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5158759925 | ||||||||
| FaxNumber: | 5158759923 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 PLEASANT ST STE 618 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5158759090 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2017 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 086376 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.