Provider Demographics
NPI:1164521670
Name:GRANATH, BRADFORD DEAHL (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:DEAHL
Last Name:GRANATH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057
Mailing Address - Country:US
Mailing Address - Phone:425-690-3445
Mailing Address - Fax:425-690-9445
Practice Address - Street 1:3915 TALBOT RD S STE 401
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5738
Practice Address - Country:US
Practice Address - Phone:425-690-3445
Practice Address - Fax:425-690-9445
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11269207Q00000X
WAMD00025394207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV29D1045101OtherCLIA WAIVED #
NV100507165Medicaid
NV11269OtherSTATE LICENCE #
NV100507319Medicaid
NV203580193OtherTAX ID
NVCC1838OtherBLUECROSS BLUESHIELD #