Provider Demographics
NPI:1831497494
Name:GRANT, CECELIA ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:CECELIA
Middle Name:ANN
Last Name:GRANT
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 77
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:AK
Mailing Address - Zip Code:99741-0077
Mailing Address - Country:US
Mailing Address - Phone:907-656-1366
Mailing Address - Fax:907-459-3845
Practice Address - Street 1:77 ANTOSKI DRIVE
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:AK
Practice Address - Zip Code:99741
Practice Address - Country:US
Practice Address - Phone:907-656-1366
Practice Address - Fax:907-459-3845
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK976363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant