Provider Demographics
NPI:1245236744
Name:GRANT, EDWARD KEITH (PA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:KEITH
Last Name:GRANT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3708 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2404
Mailing Address - Country:US
Mailing Address - Phone:478-745-4206
Mailing Address - Fax:478-254-5463
Practice Address - Street 1:3708 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2404
Practice Address - Country:US
Practice Address - Phone:478-745-4206
Practice Address - Fax:478-254-5463
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA542228866EMedicaid
GAP00758778OtherMEDICARE RAILROAD
GAP98768Medicare UPIN
GA202I973564Medicare PIN