Provider Demographics
NPI:1629482708
Name:MATHISON, GRANT WILLIAM
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:WILLIAM
Last Name:MATHISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 SAINT FRANCIS AVE
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-3374
Mailing Address - Country:US
Mailing Address - Phone:952-993-7750
Mailing Address - Fax:
Practice Address - Street 1:1415 SAINT FRANCIS AVE
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-3374
Practice Address - Country:US
Practice Address - Phone:952-993-7750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105237207X00000X
MN67362207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery