Healthcare Provider Details

I. General information

NPI: 1205896172
Provider Name (Legal Business Name): JEFFREY B GRANT P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1649 LUCERNE ST STE A & B
MINDEN NV
89423-4363
US

IV. Provider business mailing address

1111 EMERALD BAY RD
SOUTH LAKE TAHOE CA
96150-6207
US

V. Phone/Fax

Practice location:
  • Phone: 775-782-1603
  • Fax: 775-782-1629
Mailing address:
  • Phone: 530-543-5652
  • Fax: 530-541-8723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number951
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: