MEDICARE: DEVON ORAL 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

General Provider Information

NPI Number	:	1306798442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVON ORAL GRANT PA-C

Provider Business Mailing Address
First Line	:	528 BERGENIA LOOP
Second Line	:
City	:	BEAR
State	:	DE
Zip	:	19701-4883
Country	:	US
Telephone Number	:	302-391-4336
Fax Number	:

Provider Business Practice Location Address
First Line	:	4351 E LOHMAN AVE STE 211
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-8260
Country	:	US
Telephone Number	:	575-532-9755
Fax Number	:

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

Provider Enumeration Date	:	02/11/2026
Last Update Date	:	02/11/2026

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Directions to “ DEVON ORAL GRANT PA-C” Practice Location

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