Provider Demographics
NPI:1114348737
Name:GRANT, ROMAN BENJAMIN CARROLL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROMAN
Middle Name:BENJAMIN CARROLL
Last Name:GRANT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:BENJAMIN
Other - Middle Name:C
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:MC019
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-1969
Practice Address - Fax:616-391-6248
Is Sole Proprietor?:No
Enumeration Date:2013-12-27
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-1155363A00000X
MI5601006899363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant