Provider Demographics
NPI:1659017713
Name:FERRELL, GRANT CARLYLE (PA)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:CARLYLE
Last Name:FERRELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 YORKSHIRE TRCE SE
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-4856
Mailing Address - Country:US
Mailing Address - Phone:419-602-2869
Mailing Address - Fax:
Practice Address - Street 1:4050 W BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-3767
Practice Address - Country:US
Practice Address - Phone:561-549-9090
Practice Address - Fax:561-549-9091
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.008676RX363A00000X
FL363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical