Provider Demographics
NPI:1346996600
Name:WESTBROOK, GRANT
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:WESTBROOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 BLUE MOON XING APT 932
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-7605
Mailing Address - Country:US
Mailing Address - Phone:678-823-0741
Mailing Address - Fax:
Practice Address - Street 1:105 GRAND CENTRAL BLVD STE 108
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4148
Practice Address - Country:US
Practice Address - Phone:912-748-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant