Individual
DALE COURTNEY GRANTHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1110 BLUE SAGE RD NE, RIO RANCHO, NM 87144-5763
(509) 942-4793
Mailing address
3129 N 109TH TER, KANSAS CITY, KS 66109-8901
(509) 942-4793
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
MD00041473
WA
207P00000X
Emergency Medicine Physician
MD2012-0049193
NM
207PE0004X
Emergency Medical Services (Emergency Medicine) Physician
Primary
MD2012-0049193
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0202687
LIWA
WA
01
—
3075GR
BSWA
WA
01
—
605960008
DEEOIC
WA
05
—
8317067
—
WA
Enumeration date
06/08/2006
Last updated
05/30/2023
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