Provider Demographics
NPI:1760421085
Name:GRANGER, RICHARD J (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:GRANGER
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 1:2930 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3832
Mailing Address - Country:US
Mailing Address - Phone:425-261-1500
Mailing Address - Fax:425-261-1515
Practice Address - Street 1:2930 MAPLE ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3832
Practice Address - Country:US
Practice Address - Phone:425-261-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60219907207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN400033100Medicaid
H36749Medicare UPIN
MN400033100Medicaid