Provider Demographics
NPI:1568419851
Name:GRANDA-CAMERON, CLARA IV (CRNP)
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:GRANDA-CAMERON
Suffix:IV
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 EAST 17TH STREET
Mailing Address - Street 2:BAIRD HALL, 12 FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003
Mailing Address - Country:US
Mailing Address - Phone:212-844-1462
Mailing Address - Fax:212-844-1503
Practice Address - Street 1:350 EAST 17TH STREET
Practice Address - Street 2:BAIRD HALL, 12 FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-9542
Practice Address - Country:US
Practice Address - Phone:212-844-1462
Practice Address - Fax:212-844-1503
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY370022363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA067260FYYMedicare PIN