Healthcare Provider Details

I. General information

NPI: 1245785732
Provider Name (Legal Business Name): SHO GRANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 W THUNDERBIRD RD STE B200
GLENDALE AZ
85306-4664
US

IV. Provider business mailing address

5750 W THUNDERBIRD RD SUITE B200
GLENDALE AZ
85306-4660
US

V. Phone/Fax

Practice location:
  • Phone: 602-375-1700
  • Fax: 602-978-1225
Mailing address:
  • Phone: 602-375-1700
  • Fax: 602-978-1225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: