Provider Demographics
NPI:1124064548
Name:GRANT, JED D (PA-C)
Entity type:Individual
Prefix:MR
First Name:JED
Middle Name:D
Last Name:GRANT
Suffix:
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 1:2550 NORTH HOLLYWOOD WAY
Mailing Address - Street 2:SUITE 209
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-5019
Mailing Address - Country:US
Mailing Address - Phone:818-557-0135
Mailing Address - Fax:818-557-1394
Practice Address - Street 1:869 NORTH CHERRY STREET
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-2287
Practice Address - Country:US
Practice Address - Phone:559-695-3450
Practice Address - Fax:559-685-3869
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15317363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15312Medicaid
CAS96052Medicare UPIN
CADS160ZMedicare PIN
CAPA15312Medicaid