Provider Demographics
NPI:1093305773
Name:BREMER, GRANT (PA-C)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:BREMER
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 1:9255 BLUE HOUSE RD APT 4301
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4258
Mailing Address - Country:US
Mailing Address - Phone:260-705-4285
Mailing Address - Fax:
Practice Address - Street 1:9255 BLUE HOUSE RD APT 4301
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4258
Practice Address - Country:US
Practice Address - Phone:260-705-4285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1179282363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical