Provider Demographics
NPI:1538322151
Name:GRANLUND, KRISTIN M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:M
Last Name:GRANLUND
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DIVISION OF GASTROENTEROLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-6853
Mailing Address - Fax:414-955-6214
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DIVISION OF GASTROENTEROLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-6853
Practice Address - Fax:414-955-6214
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI2282363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1538322151Medicaid
WI736011280Medicare PIN