Provider Demographics
NPI:1750660528
Name:GRANDERSON, PETER MARK (APN, FNP-C)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:MARK
Last Name:GRANDERSON
Suffix:
Gender:M
Credentials:APN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:614 E EMMA AVENUE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-4469
Mailing Address - Country:US
Mailing Address - Phone:479-751-7417
Mailing Address - Fax:479-751-4898
Practice Address - Street 1:1500 N MOUNT OLIVE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-9509
Practice Address - Country:US
Practice Address - Phone:479-524-8175
Practice Address - Fax:479-524-8176
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARA03579363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily