Provider Demographics
NPI:1831445402
Name:GRANT, LEROY (PHYSICIANS ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:LEROY
Middle Name:
Last Name:GRANT
Suffix:
Gender:M
Credentials:PHYSICIANS ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12215 DALEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-1119
Mailing Address - Country:US
Mailing Address - Phone:301-946-0806
Mailing Address - Fax:
Practice Address - Street 1:12215 DALEWOOD DR
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-1119
Practice Address - Country:US
Practice Address - Phone:301-946-0806
Practice Address - Fax:301-946-0806
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA165363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical