Healthcare Provider Details

I. General information

NPI: 1508816570
Provider Name (Legal Business Name): GRANT THOMAS LAND PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 OLD MCDONOUGH HWY SE, SUITE E
CONYERS GA
30094-7788
US

IV. Provider business mailing address

6175 NEWTON DR NE
COVINGTON GA
30014-2690
US

V. Phone/Fax

Practice location:
  • Phone: 770-922-9222
  • Fax: 770-504-6318
Mailing address:
  • Phone: 770-787-6900
  • Fax: 770-787-6962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004108
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number004108
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: