Healthcare Provider Details

I. General information

NPI: 1013795921
Provider Name (Legal Business Name): OLIVIA GRACE GRANGER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2023
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W GONZALES RD
OXNARD CA
93036-3336
US

IV. Provider business mailing address

1040 FLYNN RD
CAMARILLO CA
93012-5092
US

V. Phone/Fax

Practice location:
  • Phone: 805-988-0053
  • Fax: 805-988-0554
Mailing address:
  • Phone: 805-673-3930
  • Fax: 805-659-3217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA63576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: