Provider Demographics
NPI:1073920005
Name:GRANTHAM, KRISTA (PA)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14603 HUEBNER ROAD STE 28101 BLDG. 28
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-0546
Mailing Address - Country:US
Mailing Address - Phone:210-614-7074
Mailing Address - Fax:210-614-7074
Practice Address - Street 1:14603 HUEBNER RD STE 28101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-5497
Practice Address - Country:US
Practice Address - Phone:210-614-7074
Practice Address - Fax:210-614-7091
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-22
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant