Provider Demographics
NPI:1295763274
Name:GRANT, PAULETTE KATHLEEN (PAC)
Entity type:Individual
Prefix:MRS
First Name:PAULETTE
Middle Name:KATHLEEN
Last Name:GRANT
Suffix:
Gender:F
Credentials:PAC
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 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-609-1112
Mailing Address - Fax:419-502-3537
Practice Address - Street 1:112 INDEPENDENCE WAY STE 110
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:OH
Practice Address - Zip Code:43410-9812
Practice Address - Country:US
Practice Address - Phone:419-483-9000
Practice Address - Fax:419-483-9003
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-0434363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50-00-0434OtherPHYSICIAN ASSISTANT REG