Healthcare Provider Details

I. General information

NPI: 1407592215
Provider Name (Legal Business Name): WILLIAM JAREL GRANT SURGICAL ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14231 E 1ST DR UNIT 203
AURORA CO
80011-3818
US

IV. Provider business mailing address

PO BOX 440216
AURORA CO
80044-0216
US

V. Phone/Fax

Practice location:
  • Phone: 720-955-0456
  • Fax:
Mailing address:
  • Phone: 720-955-0456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA.0002850
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberST.0001857
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: