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1063075224 NPI number — GRANT ROBERT CARLISLE

NPI Number: 1063075224
Health Care Provider/Practitioner: GRANT ROBERT CARLISLE

Information about “1063075224” NPI (GRANT ROBERT CARLISLE) exists in 1063075224 in HTML format HTML  |  1063075224 in plain Text format TXT  |  1063075224 in PDF (Portable Document Format) PDF  |  1063075224 in an XML format XML  formats.

NPI Number : 1063075224 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1063075224",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "CARLISLE",
    "FirstName": "GRANT",
    "MiddleName": "ROBERT",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "701 PARK AVE",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "MINNEAPOLIS",
    "MailingAddressStateName": "MN",
    "MailingAddressPostalCode": "55415-1623",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "612-873-3000",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "1542 GOLF COURSE RD STE 201",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "GRAND RAPIDS",
    "PracticeLocationAddressStateName": "MN",
    "PracticeLocationAddressPostalCode": "55744-3537",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "218-326-3433",
    "PracticeLocationAddressFaxNumber": "218-326-3435",
    "EnumerationDate": "04/15/2019",
    "LastUpdateDate": "01/16/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "207W00000X",
          "TaxonomyName": "Ophthalmology Physician",
          "LicenseNumber": "MD481576",
          "LicenseNumberStateCode": "PA",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "207W00000X",
          "TaxonomyName": "Ophthalmology Physician",
          "LicenseNumber": "76307",
          "LicenseNumberStateCode": "MN",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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