Provider Demographics
NPI:1174244396
Name:GRUBER, PEYTON VACALA (PA-S)
Entity type:Individual
Prefix:
First Name:PEYTON
Middle Name:VACALA
Last Name:GRUBER
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 RAILROAD AVE UNIT 429
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3996
Mailing Address - Country:US
Mailing Address - Phone:912-432-0541
Mailing Address - Fax:
Practice Address - Street 1:339 RAILROAD AVE UNIT 429
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-3996
Practice Address - Country:US
Practice Address - Phone:912-432-0541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1190005363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant