Provider Demographics
NPI:1770279408
Name:GULLICKSON, GRANT (PA-C)
Entity type:Individual
Prefix:MR
First Name:GRANT
Middle Name:
Last Name:GULLICKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:1900 SILVER LAKE RD NW STE 110
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-1789
Practice Address - Country:US
Practice Address - Phone:651-628-9566
Practice Address - Fax:651-628-0411
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN14410363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant