Provider Demographics
NPI:1912539628
Name:GRANT, ABIGAIL RENEE
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:RENEE
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:NITRO
Mailing Address - State:WV
Mailing Address - Zip Code:25143-1270
Mailing Address - Country:US
Mailing Address - Phone:304-550-7153
Mailing Address - Fax:
Practice Address - Street 1:123 MAIN AVE
Practice Address - Street 2:
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-1270
Practice Address - Country:US
Practice Address - Phone:304-550-7153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant