Provider Demographics
NPI:1205287174
Name:GRADY, SAMUEL REED (PA)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:REED
Last Name:GRADY
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 1:100 MCGREGOR STREET
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MCGREGOR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-3730
Practice Address - Country:US
Practice Address - Phone:603-668-3545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019735363AM0700X
NH1287363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical