Provider Demographics
NPI:1043286222
Name:GRANRUD, MARK A (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:GRANRUD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 W GEORGIA
Mailing Address - Street 2:SUITE 115
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686
Mailing Address - Country:US
Mailing Address - Phone:208-463-3000
Mailing Address - Fax:208-463-3034
Practice Address - Street 1:215 E HAWAII AVENUE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686
Practice Address - Country:US
Practice Address - Phone:208-463-3000
Practice Address - Fax:208-463-3034
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA621363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P98229Medicare UPIN