Provider Demographics
NPI:1669829933
Name:GRENNAN, MICHAEL DWYER
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DWYER
Last Name:GRENNAN
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:PO BOX 5299
Mailing Address - Street 2:MS: 820-5-PCO
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0299
Mailing Address - Country:US
Mailing Address - Phone:253-459-8009
Mailing Address - Fax:
Practice Address - Street 1:4779 POINT FOSDICK DR STE 500
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-2318
Practice Address - Country:US
Practice Address - Phone:253-530-8460
Practice Address - Fax:253-530-8465
Is Sole Proprietor?:No
Enumeration Date:2016-05-17
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60805134363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant