Provider Demographics
NPI:1265903496
Name:MANSELL, GRIFFIN NEIL (PA-C)
Entity type:Individual
Prefix:
First Name:GRIFFIN
Middle Name:NEIL
Last Name:MANSELL
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 1:2885 S LORIEN CT
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-2100
Mailing Address - Country:US
Mailing Address - Phone:801-503-8445
Mailing Address - Fax:
Practice Address - Street 1:1619 NW HAWTHORNE AVE STE 201
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-6009
Practice Address - Country:US
Practice Address - Phone:541-507-1881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2022-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA191109207N00000X
UT10995993-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology