Provider Demographics
NPI:1629290580
Name:GRANDOIT, JEAN JOSEPH (PHYSICIAN'S ASSISTAN)
Entity Type:Individual
Prefix:MR
First Name:JEAN
Middle Name:JOSEPH
Last Name:GRANDOIT
Suffix:
Gender:M
Credentials:PHYSICIAN'S ASSISTAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O.BOX 100823
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-0823
Mailing Address - Country:US
Mailing Address - Phone:646-330-8254
Mailing Address - Fax:
Practice Address - Street 1:2176 NOSTRAND AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-0823
Practice Address - Country:US
Practice Address - Phone:646-330-8254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002867363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical