Healthcare Provider Details

I. General information

NPI: 1912092842
Provider Name (Legal Business Name): JEFFREY S GRANDE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NEW BERN AVE
RALEIGH NC
27610-1231
US

IV. Provider business mailing address

818 CONGRESS ST
PORTLAND ME
04102-3112
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-0554
  • Fax:
Mailing address:
  • Phone: 207-773-8161
  • Fax: 207-773-1489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110008498
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-02529
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: