Provider Demographics
NPI:1609376771
Name:FRAGASSI, GRANT (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:FRAGASSI
Suffix:
Gender:M
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 GREEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:CHURCHVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18966-1613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 GREEN VALLEY DR
Practice Address - Street 2:
Practice Address - City:CHURCHVILLE
Practice Address - State:PA
Practice Address - Zip Code:18966-1613
Practice Address - Country:US
Practice Address - Phone:215-962-0749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0064372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer