Provider Demographics
NPI:1073304721
Name:GRANDGENETT, COLIN (PA)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:GRANDGENETT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 COUNTY ROAD 14
Mailing Address - Street 2:
Mailing Address - City:WAHOO
Mailing Address - State:NE
Mailing Address - Zip Code:68066-4034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3100 N 14TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-2134
Practice Address - Country:US
Practice Address - Phone:402-477-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant