Provider Demographics
NPI:1609171347
Name:GRANTHAM, LAURA S (PAC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:S
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:NICOLE
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C, MHS, LAT
Mailing Address - Street 1:1400 E. KINCAID STREET
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:2320 FREEWAY DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5445
Practice Address - Country:US
Practice Address - Phone:360-428-2550
Practice Address - Fax:360-428-6402
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL29992255A2300X
WAPA60617391363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant