Provider Demographics
NPI:1407924293
Name:GERNER, GRANT (MD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:
Last Name:GERNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 HARKLE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4782
Mailing Address - Country:US
Mailing Address - Phone:505-795-7735
Mailing Address - Fax:
Practice Address - Street 1:539 HARKLE RD
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4782
Practice Address - Country:US
Practice Address - Phone:505-795-7735
Practice Address - Fax:505-795-7732
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM90-196207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF9204Medicaid
NM30154OtherLOVELACE
NM30154OtherLOVELACE