1295763274 NPI number — MRS. PAULETTE KATHLEEN GRANT P.A.C.

Table of content: MRS. PAULETTE KATHLEEN GRANT P.A.C. (NPI 1295763274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295763274 NPI number — MRS. PAULETTE KATHLEEN GRANT P.A.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANT
Provider First Name:
PAULETTE
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295763274
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 378
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDUSKY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44871-0378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-609-1112
Provider Business Mailing Address Fax Number:
419-502-3537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 INDEPENDENCE WAY STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLYDE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43410-9812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-483-9000
Provider Business Practice Location Address Fax Number:
419-483-9003
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  50-00-0434 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 50-00-0434 . This is a "PHYSICIAN ASSISTANT REG" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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