Provider Demographics
NPI:1457048324
Name:GRANGER, ETHAN D
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:D
Last Name:GRANGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1912 HH HWY
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:MO
Mailing Address - Zip Code:65606-8296
Mailing Address - Country:US
Mailing Address - Phone:816-518-7725
Mailing Address - Fax:816-235-5187
Practice Address - Street 1:1 UNIVERSITY OF NEW MEXICO MSC11 6025
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-5062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-20
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2024-0038363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant