Provider Demographics
NPI:1568521540
Name:GRANT, LONNIE L (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LONNIE
Middle Name:L
Last Name:GRANT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2091 BOX BUTTE AVE
Mailing Address - Street 2:STE 500
Mailing Address - City:ALLIANCE
Mailing Address - State:NE
Mailing Address - Zip Code:69301-4456
Mailing Address - Country:US
Mailing Address - Phone:308-623-2139
Mailing Address - Fax:
Practice Address - Street 1:2107 BOX BUTTE AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-4415
Practice Address - Country:US
Practice Address - Phone:308-762-7244
Practice Address - Fax:308-762-6657
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00165962OtherRR MEDICARE - SFC
NE38772OtherBCBSNE
970016869OtherRR MEDICARE - BBGH
NE506729276Medicaid
277966Medicare ID - Type UnspecifiedSANDHILLS FAMILY CENTER
273342Medicare ID - Type UnspecifiedBBGH - PART B