=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699582304
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRANTHAM MEDICAL, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2024
-----------------------------------------------------
Last Update Date | 12/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 TERRELL RD UNIT 9
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78209-6329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-221-6903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6141
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78209-0141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KRISTA GRANTHAM
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 830-221-6903
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------