Provider Demographics
NPI:1225805310
Name:GRANT, GAVYNN MICHAEL (PCT,MA,NA)
Entity Type:Individual
Prefix:
First Name:GAVYNN
Middle Name:MICHAEL
Last Name:GRANT
Suffix:
Gender:M
Credentials:PCT,MA,NA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 BALDWIN RD
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-6200
Mailing Address - Country:US
Mailing Address - Phone:186-491-8529
Mailing Address - Fax:
Practice Address - Street 1:55 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:NC
Practice Address - Zip Code:28734-2651
Practice Address - Country:US
Practice Address - Phone:828-369-4244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCX2D6M7N3207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services