Healthcare Provider Details

I. General information

NPI: 1023017795
Provider Name (Legal Business Name): CATHERINE CORISH GRANT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CATHERINE ANGLIN CORISH PA-C

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 03/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 EXCHANGE STREET SUITE B-7
RICHMOND HILL GA
31324
US

IV. Provider business mailing address

114 GREAT OAKS WAY
RICHMOND HILL GA
31324-5461
US

V. Phone/Fax

Practice location:
  • Phone: 912-756-2273
  • Fax:
Mailing address:
  • Phone: 912-596-8868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004290
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: