Provider Demographics
NPI:1629029889
Name:ANDERSON, GRANT PETER (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:PETER
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1665 ASPEN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89519-0685
Mailing Address - Country:US
Mailing Address - Phone:775-846-3301
Mailing Address - Fax:
Practice Address - Street 1:5345 RENO CORPORATE DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511
Practice Address - Country:US
Practice Address - Phone:775-825-5008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3156207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016029Medicaid
NV002016029Medicaid
NVV101871Medicare ID - Type UnspecifiedMEDICARE