Provider Demographics
NPI:1689960171
Name:GRANNEMAN, NATHAN LEE (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:LEE
Last Name:GRANNEMAN
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 1:401 N KEENE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6625
Mailing Address - Country:US
Mailing Address - Phone:573-876-1600
Mailing Address - Fax:573-876-1606
Practice Address - Street 1:401 N KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6625
Practice Address - Country:US
Practice Address - Phone:573-876-1600
Practice Address - Fax:573-876-1606
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120235322083X0100X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200008322Medicaid