Provider Demographics
NPI:1982698734
Name:GRANGER, DAVID L (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:GRANGER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 PARK FOREST DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7331
Mailing Address - Country:US
Mailing Address - Phone:231-935-5770
Mailing Address - Fax:231-935-5878
Practice Address - Street 1:4100 PARK FOREST DR
Practice Address - Street 2:SUITE 210
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7331
Practice Address - Country:US
Practice Address - Phone:231-935-5770
Practice Address - Fax:231-935-5878
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704120471367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4297536Medicaid
MI430B810310OtherBCBS TSC
MI430049568OtherMEDICARE RAIL ROAD TSC
MI0B86029001Medicare ID - Type Unspecified
MI0M58250001Medicare PIN
R65401Medicare UPIN
MICG1308Medicare PIN
MI0M58250001Medicare ID - Type UnspecifiedMEDICARE TSC
MI4297536Medicaid