Provider Demographics
NPI:1881889830
Name:GRAMMER, SHAUN L (PA-C)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:L
Last Name:GRAMMER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 642117
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-8117
Mailing Address - Country:US
Mailing Address - Phone:402-398-6254
Mailing Address - Fax:402-829-8513
Practice Address - Street 1:7261 MERCY RD
Practice Address - Street 2:NORTH BUILDING
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2311
Practice Address - Country:US
Practice Address - Phone:402-398-6254
Practice Address - Fax:402-829-8513
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA363AM0700X
NE1827363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE099928060Medicare PIN