Healthcare Provider Details

I. General information

NPI: 1326763921
Provider Name (Legal Business Name): MADELINE GRANT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N ORANGE AVE STE 181
ORLANDO FL
32804-4675
US

IV. Provider business mailing address

2501 N ORANGE AVE STE 181
ORLANDO FL
32804-4675
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-2040
  • Fax: 407-303-2040
Mailing address:
  • Phone: 407-303-2040
  • Fax: 407-303-2040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116601
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: