Provider Demographics
NPI:1588603542
Name:GRANDELL, CHRISTIAN L (PAC)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:L
Last Name:GRANDELL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 LAKE HAVASU AVE S STE 204
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6526
Mailing Address - Country:US
Mailing Address - Phone:928-453-1970
Mailing Address - Fax:928-855-7229
Practice Address - Street 1:297 LAKE HAVASU AVE S STE 204
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6526
Practice Address - Country:US
Practice Address - Phone:928-453-1970
Practice Address - Fax:928-855-7229
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2719363A00000X, 363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P61218Medicare UPIN
AZ270659Medicare ID - Type Unspecified