MEDICARE: PETER MARK GRANDERSON APN, FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	A03579	AR

General Provider Information

NPI Number	:	1750660528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER MARK GRANDERSON APN, FNP-C

Provider Business Mailing Address
First Line	:	614 E EMMA AVENUE
Second Line	:	SUITE 300
City	:	SPRINGDALE
State	:	AR
Zip	:	72764-4469
Country	:	US
Telephone Number	:	479-751-7417
Fax Number	:	479-751-4898

Provider Business Practice Location Address
First Line	:	1500 N MOUNT OLIVE ST
Second Line	:	SUITE 1
City	:	SILOAM SPRINGS
State	:	AR
Zip	:	72761-9509
Country	:	US
Telephone Number	:	479-524-8175
Fax Number	:	479-524-8176

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2011
Last Update Date	:	09/23/2016

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