Provider Demographics
NPI:1467095851
Name:GRANT, SARA INABNIT
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:INABNIT
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 NELSON BLVD
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-4027
Practice Address - Country:US
Practice Address - Phone:843-355-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3589363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4395PAMedicaid