Provider Demographics
NPI:1790754638
Name:GRANDON, MARY E (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:GRANDON
Suffix:
Gender:F
Credentials:PA-C
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 70
Mailing Address - Street 2:
Mailing Address - City:DAWES
Mailing Address - State:WV
Mailing Address - Zip Code:25054
Mailing Address - Country:US
Mailing Address - Phone:304-734-2040
Mailing Address - Fax:304-734-2047
Practice Address - Street 1:107 KOONTZ AVE. STE. 200
Practice Address - Street 2:
Practice Address - City:CLENDENIN
Practice Address - State:WV
Practice Address - Zip Code:25045
Practice Address - Country:US
Practice Address - Phone:304-548-7272
Practice Address - Fax:304-548-7149
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00616363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVGRPA15395Medicare ID - Type UnspecifiedINDIVIDUAL
WVP07436Medicare UPIN