Provider Demographics
NPI:1740063247
Name:GRANT, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 E OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-7092
Mailing Address - Country:US
Mailing Address - Phone:805-737-3300
Mailing Address - Fax:
Practice Address - Street 1:136 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-7002
Practice Address - Country:US
Practice Address - Phone:805-736-1253
Practice Address - Fax:805-736-5355
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant