Healthcare Provider Details

I. General information

NPI: 1356538763
Provider Name (Legal Business Name): WILLIAM ALFONSO GRANILLO PHYSICIAN ASSISTAN T
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2007
Last Update Date: 09/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 N ALTA AVE
DINUBA CA
93618-3089
US

IV. Provider business mailing address

4690 N BENGSTON AVE
FRESNO CA
93705-0309
US

V. Phone/Fax

Practice location:
  • Phone: 559-595-1000
  • Fax: 559-591-6322
Mailing address:
  • Phone: 559-226-1500
  • Fax: 559-226-1500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10807
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: