Provider Demographics
NPI:1235159260
Name:KRANT, GRETCHEN JANINIA (MSPA-C)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:JANINIA
Last Name:KRANT
Suffix:
Gender:F
Credentials:MSPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6035 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3256
Mailing Address - Country:US
Mailing Address - Phone:704-295-3000
Mailing Address - Fax:
Practice Address - Street 1:724 AUBREY BELL DRIVE
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5055
Practice Address - Country:US
Practice Address - Phone:704-295-3550
Practice Address - Fax:704-295-3556
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03037363A00000X
PAMA051978363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1679JOtherBCBSNC
NC8102326Medicaid
SC1298PAMedicaid
9965514OtherAETNA
NCP01103054OtherRAILROAD MEDICARE
9965514OtherAETNA
NCP01103054OtherRAILROAD MEDICARE
PA086264J5GMedicare ID - Type Unspecified