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General NPI Number Information
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NPI Number | 1992345045
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Entity Type | Individual
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Provider Name | MR. MATTHEW JOSEPH GRANNER
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Gender | Male
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Dates
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Enumeration Date | 01/07/2020
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Last Update Date | 08/10/2023
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Provider Practice Location Address
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Address Line | 2035 SAINT JOHN AVE
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City | DYERSBURG
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State | TN
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Zip | 38024-2247
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Country | US
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Telephone | 316-619-8257
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Fax |
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Provider Business Mailing Address
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Address Line | 120 GENE ADAMS RD
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City | MARTIN
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State | TN
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Zip | 38237-8146
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Country | US
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Telephone | 731-514-3708
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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 |
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License Number State |
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