Individual
DR. BRADFORD DEAHL GRANATH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3915 TALBOT RD S STE 401, RENTON, WA 98055-5738
(425) 690-3445
(425) 690-9445
Mailing address
3600 LIND AVE SW, SUITE 100 ATTN CREDENTIALING, RENTON, WA 98057
(425) 690-3445
(425) 690-9445
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
11269
NV
207Q00000X
Family Medicine Physician
Primary
MD00025394
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100507165
—
NV
05
—
100507319
—
NV
01
—
11269
STATE LICENCE #
NV
01
—
203580193
TAX ID
NV
01
—
29D1045101
CLIA WAIVED #
NV
01
—
CC1838
BLUECROSS BLUESHIELD #
NV
Enumeration date
09/21/2006
Last updated
07/16/2019
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