Individual
MARK E GRANDON
Active
Individual
MARK E GRANDON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
PA155
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000689934
ANTHEM - CTS
KY
01
—
121030
SIHO - CTS
KY
01
—
1299470001
PTAN
KY
01
—
50032501
PASSPORT/PASSPORT ADVANTAGE - CTS
KY
05
—
95001558
—
KY
Enumeration date
06/06/2006
Last updated
07/09/2016
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