Provider Demographics
NPI:1689970014
Name:PAIK, GRACE (CRNP)
Entity type:Individual
Prefix:MISS
First Name:GRACE
Middle Name:
Last Name:PAIK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 LOCUST ST THIRD FLOOR
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5400
Mailing Address - Country:US
Mailing Address - Phone:215-985-4448
Mailing Address - Fax:215-732-1145
Practice Address - Street 1:1233 LOCUST STREET 4TH FLOOR
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5453
Practice Address - Country:US
Practice Address - Phone:215-790-1788
Practice Address - Fax:215-732-5490
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010854363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102970866Medicaid