Provider Demographics
NPI:1336364942
Name:GRANT, GREGORY LAYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:LAYNE
Last Name:GRANT
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 1:136 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-2708
Mailing Address - Country:US
Mailing Address - Phone:304-539-6214
Mailing Address - Fax:304-201-3159
Practice Address - Street 1:610 DAMES ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-2652
Practice Address - Country:US
Practice Address - Phone:304-201-3150
Practice Address - Fax:304-201-3159
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV 871363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant