Provider Demographics
NPI:1013055482
Name:YELLIOTT, GRANT ALEXANDER II (PA C)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:ALEXANDER
Last Name:YELLIOTT
Suffix:II
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:1717 S J ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4933
Practice Address - Country:US
Practice Address - Phone:253-426-6660
Practice Address - Fax:253-426-6250
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8490021Medicaid
WA1493YEOtherBSWA
WA0221347OtherLIWA
WA1493YEOtherBSWA