Provider Demographics
NPI:1023017795
Name:GRANT, CATHERINE CORISH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CATHERINE
Middle Name:CORISH
Last Name:GRANT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:CATHERINE
Other - Middle Name:ANGLIN
Other - Last Name:CORISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:114 GREAT OAKS WAY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-5461
Mailing Address - Country:US
Mailing Address - Phone:912-596-8868
Mailing Address - Fax:
Practice Address - Street 1:60 EXCHANGE STREET
Practice Address - Street 2:SUITE B-7
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324
Practice Address - Country:US
Practice Address - Phone:912-756-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0288PAMedicaid
GA328595480BMedicaid
Q22797Medicare UPIN
GA97WCFTVMedicare ID - Type Unspecified