Provider Demographics
NPI:1003597956
Name:GRANADOS, GISELLE (OWNER)
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:
Last Name:GRANADOS
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5335 S STONEBOROUGH ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67217-6512
Mailing Address - Country:US
Mailing Address - Phone:316-202-8701
Mailing Address - Fax:
Practice Address - Street 1:810 W DOUGLAS AVE STE C
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-6133
Practice Address - Country:US
Practice Address - Phone:316-202-8701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular SonographyGroup - Multi-Specialty