Individual
BRIAN E GRANVALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
190 E BANNOCK ST, BOISE, ID 83712-6241
(208) 381-2094
(208) 381-1791
Mailing address
PO BOX 1108, CORVALLIS, OR 97339-1108
(208) 381-2094
(208) 381-1791
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
PA-1042
ID
363A00000X
Physician Assistant
0110002940
VA
363A00000X
Physician Assistant
PA 00846
OR
363A00000X
Physician Assistant
PA10004399
WA
363AS0400X
Surgical Physician Assistant
C04233
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8326142
—
WA
Enumeration date
02/13/2006
Last updated
01/31/2022
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