Provider Demographics
NPI:1396219408
Name:GRANATA, CARLY COOK (PA-C)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:COOK
Last Name:GRANATA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:JANE
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10236 LAKE ARBOR WAY
Mailing Address - Street 2:
Mailing Address - City:MITCHELLVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3113
Mailing Address - Country:US
Mailing Address - Phone:404-362-8402
Mailing Address - Fax:
Practice Address - Street 1:10236 LAKE ARBOR WAY
Practice Address - Street 2:
Practice Address - City:MITCHELLVILLE
Practice Address - State:MD
Practice Address - Zip Code:20721-3113
Practice Address - Country:US
Practice Address - Phone:240-436-2840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0008389363A00000X
VA0110007055363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty