Provider Demographics
NPI:1710326509
Name:GRANT, WAYNE KEITH (APRN)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:KEITH
Last Name:GRANT
Suffix:
Gender:M
Credentials:APRN
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 1956
Mailing Address - Street 2:1090 GOAT SPRINGS RD
Mailing Address - City:TAOS PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87571
Mailing Address - Country:US
Mailing Address - Phone:505-758-4224
Mailing Address - Fax:505-751-5210
Practice Address - Street 1:1090 GOAT SPRINGS RD
Practice Address - Street 2:
Practice Address - City:TAOS PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:505-758-4224
Practice Address - Fax:505-751-5210
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN961075363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily