Provider Demographics
NPI:1326763921
Name:GRANT, MADELINE (PA-C)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:836 SUNSET LAKE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-7555
Practice Address - Country:US
Practice Address - Phone:941-408-0500
Practice Address - Fax:941-496-8558
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115856800Medicaid