Provider Demographics
NPI:1457821795
Name:VICKERMAN, GRANT MICHAEL
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:MICHAEL
Last Name:VICKERMAN
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 1:22037 181ST ST NW
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-8243
Mailing Address - Country:US
Mailing Address - Phone:763-567-0415
Mailing Address - Fax:
Practice Address - Street 1:22037 181ST ST NW
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-8243
Practice Address - Country:US
Practice Address - Phone:763-567-0415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer