Provider Demographics
NPI:1205809852
Name:GRANVALL, BRIAN E (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:E
Last Name:GRANVALL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1108
Mailing Address - Country:US
Mailing Address - Phone:208-381-2094
Mailing Address - Fax:208-381-1791
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-2094
Practice Address - Fax:208-381-1791
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002940363A00000X
WAPA10004399363A00000X
ORPA 00846363A00000X
MDC04233363AS0400X
IDPA-10422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8326142Medicaid
WAG8863702Medicare PIN
P77846Medicare UPIN
WA8326142Medicaid