Provider Demographics
NPI:1508816570
Name:LAND, GRANT THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:THOMAS
Last Name:LAND
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6175 NEWTON DR NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2690
Mailing Address - Country:US
Mailing Address - Phone:770-787-6900
Mailing Address - Fax:770-787-6962
Practice Address - Street 1:545 VENTURE CT
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:GA
Practice Address - Zip Code:31064-7788
Practice Address - Country:US
Practice Address - Phone:706-468-7002
Practice Address - Fax:877-870-3481
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004108363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA004108OtherPA LICENSE NUMBER
GA003200095AMedicaid
GAQ68555Medicare UPIN