Provider Demographics
NPI:1952099962
Name:GRANATA, MIKAYLA JENNY (PA-C)
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:JENNY
Last Name:GRANATA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MIKAYLA
Other - Middle Name:JENNY
Other - Last Name:KONECNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:360 US HIGHWAY 1 BYP UNIT 102
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7105
Mailing Address - Country:US
Mailing Address - Phone:603-410-6700
Mailing Address - Fax:603-319-8308
Practice Address - Street 1:738 HOOKSETT RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-2617
Practice Address - Country:US
Practice Address - Phone:603-384-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NH2063363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant