MEDICARE: MR. KHRISTOPHER MICHAEL GRANT PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	12403	MN

General Provider Information

NPI Number	:	1194255224
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KHRISTOPHER MICHAEL GRANT PA-C

Provider Business Mailing Address
First Line	:	1809 TRAILWAY DR APT 8
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55122-3214
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 KENNARD ST STE 100
Second Line	:
City	:	MAPLEWOOD
State	:	MN
Zip	:	55109-5466
Country	:	US
Telephone Number	:	651-232-7800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2017
Last Update Date	:	03/17/2018

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