Healthcare Provider Details

I. General information

NPI: 1568521540
Provider Name (Legal Business Name): LONNIE L GRANT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 03/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2107 BOX BUTTE AVE
ALLIANCE NE
69301-4415
US

IV. Provider business mailing address

2091 BOX BUTTE AVE STE 500
ALLIANCE NE
69301-4456
US

V. Phone/Fax

Practice location:
  • Phone: 308-762-7244
  • Fax: 308-762-6657
Mailing address:
  • Phone: 308-623-2139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number762
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: