Provider Demographics
NPI:1740954098
Name:GRANT, PATRICK MICHAEL JR
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:MICHAEL
Last Name:GRANT
Suffix:JR
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 1:3700 SW MODERN WAY APT 308
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72713-2033
Mailing Address - Country:US
Mailing Address - Phone:479-899-1555
Mailing Address - Fax:
Practice Address - Street 1:3625 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-0351
Practice Address - Country:US
Practice Address - Phone:479-246-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4153208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation