Individual
GRANT THOMAS LAND
Active
Individual
GRANT THOMAS LAND
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
004108
GA
363AM0700X
Medical Physician Assistant
Primary
004108
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003200095A
—
GA
01
—
004108
PA LICENSE NUMBER
GA
Enumeration date
05/11/2006
Last updated
05/23/2024
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