Provider Demographics
NPI:1972858025
Name:WALKER, GRANT C (PA)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:C
Last Name:WALKER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 W JEFFERSON ST STE 202
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-2732
Mailing Address - Country:US
Mailing Address - Phone:317-346-3883
Mailing Address - Fax:317-346-3141
Practice Address - Street 1:1155 W JEFFERSON ST STE 202
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-2732
Practice Address - Country:US
Practice Address - Phone:317-346-3883
Practice Address - Fax:317-346-3141
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001416363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300016851Medicaid