Provider Demographics
NPI:1932130507
Name:GRANDY, JOHNATHAN K (PA)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:K
Last Name:GRANDY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:K
Other - Last Name:GRANDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:35 MEDICAL CENTER PARKWAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330
Practice Address - Country:US
Practice Address - Phone:207-877-3400
Practice Address - Fax:207-877-3401
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010477363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant