Healthcare Provider Details

I. General information

NPI: 1295763274
Provider Name (Legal Business Name): PAULETTE KATHLEEN GRANT P.A.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 INDEPENDENCE WAY STE 110
CLYDE OH
43410-9812
US

IV. Provider business mailing address

PO BOX 378
SANDUSKY OH
44871-0378
US

V. Phone/Fax

Practice location:
  • Phone: 419-483-9000
  • Fax: 419-483-9003
Mailing address:
  • Phone: 419-609-1112
  • Fax: 419-502-3537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50-00-0434
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: