Healthcare Provider Details

I. General information

NPI: 1023622370
Provider Name (Legal Business Name): ASHLEY SUZANNE GRANATH DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY SUZANNE JONES

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

984 N MERIDIAN PL # A
WASILLA AK
99654-7215
US

IV. Provider business mailing address

525 W MONTANA DR
PALMER AK
99645-7030
US

V. Phone/Fax

Practice location:
  • Phone: 907-631-4029
  • Fax: 907-631-4128
Mailing address:
  • Phone: 907-982-1073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number166016
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: