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General NPI Number Information
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NPI Number | 1639294739
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Entity Type | Individual
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Provider Name | KARL DANIEL GRANROTH PA-C
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Gender | Male
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 03/17/2009
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Provider Practice Location Address
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Address Line | 620 LEE ST
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City | WINSLOW
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State | AZ
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Zip | 86047-2435
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Country | US
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Telephone | 928-289-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 2920 N 4TH ST
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City | FLAGSTAFF
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State | AZ
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Zip | 86004-1816
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Country | US
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Telephone | 928-213-6121
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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 | 3602
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 3602
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License Number State | AZ
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