MEDICARE: MR. RONALD GREGORY GRANT P.A.

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	PA11322	CA

General Provider Information

NPI Number	:	1740245190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RONALD GREGORY GRANT P.A.

Provider Business Mailing Address
First Line	:	350 30TH ST
Second Line	:	SUITE 407
City	:	OAKLAND
State	:	CA
Zip	:	94609-3425
Country	:	US
Telephone Number	:	510-419-0230
Fax Number	:	510-419-0273

Provider Business Practice Location Address
First Line	:	350 30TH ST
Second Line	:	SUITE 407
City	:	OAKLAND
State	:	CA
Zip	:	94609-3425
Country	:	US
Telephone Number	:	510-419-0230
Fax Number	:	510-419-0273

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

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	03/07/2023

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