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General NPI Number Information
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NPI Number | 1710326509
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Entity Type | Individual
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Provider Name | WAYNE KEITH GRANT APRN
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Gender | Male
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Dates
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Enumeration Date | 06/14/2013
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Last Update Date | 08/16/2013
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Provider Practice Location Address
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Address Line | 1090 GOAT SPRINGS RD
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City | TAOS PUEBLO
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State | NM
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Zip | 87571
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Country | US
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Telephone | 505-758-4224
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Fax | 505-751-5210
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Provider Business Mailing Address
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Address Line | PO BOX 1956 1090 GOAT SPRINGS RD
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City | TAOS PUEBLO
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State | NM
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Zip | 87571
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Country | US
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Telephone | 505-758-4224
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Fax | 505-751-5210
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RN961075
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License Number State | DC
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