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NPI Code Detail

MEDICARE: MR. OMAR CORDELL GRANT PA-C

MEDICARE: MR. OMAR CORDELL 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
1363AM0700XMedical Physician Assistant
2363AS0400XSurgical Physician Assistant
3363AM0700XMedical Physician AssistantPA9107410FL

General Provider Information

NPI Number : 1831522374
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. OMAR CORDELL GRANT PA-C
Provider Business Mailing Address
First Line : 8130 LAKEWOOD MAIN ST STE 103
Second Line :
City : LAKEWOOD RANCH
State : FL
Zip : 34202-5068
Country : US
Telephone Number : 954-551-7041
Fax Number :
Provider Business Practice Location Address
First Line : 8130 LAKEWOOD MAIN ST STE 103
Second Line :
City : LAKEWOOD RANCH
State : FL
Zip : 34202-5068
Country : US
Telephone Number : 954-551-7041
Fax Number : 941-487-0474
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/20/2013
Last Update Date : 02/10/2025

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Directions to “ MR. OMAR CORDELL GRANT PA-C” Practice Location

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