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General NPI Number Information
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NPI Number | 1194255224
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Entity Type | Individual
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Provider Name | KHRISTOPHER MICHAEL GRANT PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/12/2017
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 3100 KENNARD ST STE 100
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City | MAPLEWOOD
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State | MN
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Zip | 55109-5466
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Country | US
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Telephone | 651-232-7800
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Fax |
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Provider Business Mailing Address
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Address Line | 1809 TRAILWAY DR APT 8
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City | EAGAN
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State | MN
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Zip | 55122-3214
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 12403
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License Number State | MN
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