Provider Demographics
NPI:1386683852
Name:GRANDON, MARK E (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:GRANDON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3 AUDUBON PLAZA DR
Practice Address - Street 2:SUITE 560
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1319
Practice Address - Country:US
Practice Address - Phone:502-636-8004
Practice Address - Fax:502-636-8384
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA155363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY121030OtherSIHO - CTS
KY50032501OtherPASSPORT/PASSPORT ADVANTAGE - CTS
KY95001558Medicaid
KY000000689934OtherANTHEM - CTS
KY1299470001OtherPTAN
KY121030OtherSIHO - CTS
KYS04680Medicare UPIN
KY1299470001OtherPTAN