Provider Demographics
NPI:1740245190
Name:GRANT, RONALD GREGORY (PA)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:GREGORY
Last Name:GRANT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:350 30TH ST
Mailing Address - Street 2:SUITE 407
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3425
Mailing Address - Country:US
Mailing Address - Phone:510-419-0230
Mailing Address - Fax:510-419-0273
Practice Address - Street 1:350 30TH ST
Practice Address - Street 2:SUITE 407
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3425
Practice Address - Country:US
Practice Address - Phone:510-419-0230
Practice Address - Fax:510-419-0273
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11322363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMG0627539OtherDEA
CAMMM00345MMedicare ID - Type Unspecified