Provider Demographics
NPI:1922623297
Name:DESANTIS, GRACE G
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:G
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:G
Other - Last Name:KROTKOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST
Mailing Address - Street 2:STE 625
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:717-719-1658
Mailing Address - Fax:
Practice Address - Street 1:3410 CHAPARRAL DR APT 133
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-4930
Practice Address - Country:US
Practice Address - Phone:717-719-1658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-12
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant