Healthcare Provider Details

I. General information

NPI: 1073816641
Provider Name (Legal Business Name): GRANT THOMAS JORDAN-TAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2010
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HARVARD ST SE
MINNEAPOLIS MN
55455
US

IV. Provider business mailing address

8 VINCENT AVE S
MINNEAPOLIS MN
55405-1952
US

V. Phone/Fax

Practice location:
  • Phone: 612-229-6713
  • Fax:
Mailing address:
  • Phone: 612-229-6713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number86622
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: