Provider Demographics
NPI:1205825148
Name:COOPER, GRANT WAYNE (MSCN FNP)
Entity Type:Individual
Prefix:MR
First Name:GRANT
Middle Name:WAYNE
Last Name:COOPER
Suffix:
Gender:M
Credentials:MSCN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6336 W HONEYSUCKLE DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-1824
Mailing Address - Country:US
Mailing Address - Phone:623-204-4914
Mailing Address - Fax:623-322-1809
Practice Address - Street 1:6336 W HONEYSUCKLE DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-1824
Practice Address - Country:US
Practice Address - Phone:623-204-4914
Practice Address - Fax:623-322-1809
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP0851363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily