Provider Demographics
NPI:1114037579
Name:GRANT-DOUGHERTY, CAROL LUISA (PA)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:LUISA
Last Name:GRANT-DOUGHERTY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:LUISA
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 7007
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93539-7007
Mailing Address - Country:US
Mailing Address - Phone:661-945-5984
Mailing Address - Fax:661-951-3357
Practice Address - Street 1:43839 15TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4756
Practice Address - Country:US
Practice Address - Phone:661-945-5984
Practice Address - Fax:661-951-3357
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11959363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP46758Medicare UPIN
CAWPA11959AMedicare ID - Type Unspecified