Provider Demographics
NPI:1205896172
Name:GRANT, JEFFREY B (PA)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:B
Last Name:GRANT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5652
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:1649 LUCERNE ST
Practice Address - Street 2:STE A & B
Practice Address - City:MINDEN
Practice Address - State:NV
Practice Address - Zip Code:89423-4363
Practice Address - Country:US
Practice Address - Phone:775-782-1603
Practice Address - Fax:775-782-1629
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV951363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
101732Medicare ID - Type Unspecified
Q57920Medicare UPIN