Healthcare Provider Details

I. General information

NPI: 1407710916
Provider Name (Legal Business Name): SHANNON L GRANGER DO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12264 EL CAMINO REAL
SAN DIEGO CA
92130-3058
US

IV. Provider business mailing address

PO BOX 34120
RENO NV
89533-4120
US

V. Phone/Fax

Practice location:
  • Phone: 858-755-3937
  • Fax:
Mailing address:
  • Phone: 775-747-5050
  • Fax: 775-747-5005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: SHANNON L GRANGER
Title or Position: OWNER
Credential: DO
Phone: 858-755-3937