Provider Demographics
NPI:1790258721
Name:JANSEN, GRANT (PA)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:JANSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 GRAND AVE APT 301
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-4137
Mailing Address - Country:US
Mailing Address - Phone:563-590-7337
Mailing Address - Fax:
Practice Address - Street 1:501 S WHITE ST STE 1
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:IA
Practice Address - Zip Code:52641-2654
Practice Address - Country:US
Practice Address - Phone:319-385-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA093375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA093375Medicaid