Provider Demographics
NPI:1598990467
Name:GRANT, CHRISTA NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTA
Middle Name:NICOLE
Last Name:GRANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 E HOSPITAL DRIVE
Mailing Address - Street 2:MOTT 4-933
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-4211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 WOODS RD STE C1119
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1530
Practice Address - Country:US
Practice Address - Phone:914-493-6988
Practice Address - Fax:914-493-2994
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-21
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCTBD208600000X
CAA121328208600000X
MI4301109184390200000X
NY314041-012086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty