Provider Demographics
NPI:1578558946
Name:ANDERSON, GRANT A (PA-C)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:A
Last Name:ANDERSON
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 1:120 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:NE
Mailing Address - Zip Code:68370-2019
Mailing Address - Country:US
Mailing Address - Phone:402-768-7203
Mailing Address - Fax:402-768-4669
Practice Address - Street 1:120 PARK AVE
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:NE
Practice Address - Zip Code:68370-2019
Practice Address - Country:US
Practice Address - Phone:402-768-7203
Practice Address - Fax:402-768-4669
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NER81553Medicare UPIN
NE278802Medicare ID - Type Unspecified