Provider Demographics
NPI:1023148863
Name:GRANGER, KEVIN JOSEPH (PT A)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOSEPH
Last Name:GRANGER
Suffix:
Gender:M
Credentials:PT A
Other - Prefix:MR
Other - First Name:KEVIN
Other - Middle Name:JOSEPH
Other - Last Name:GRANGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:7 JUNIPER PL
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-5781
Mailing Address - Country:US
Mailing Address - Phone:505-261-5943
Mailing Address - Fax:
Practice Address - Street 1:4308 CARLISLE BLVD, NE
Practice Address - Street 2:SUITE 209
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107
Practice Address - Country:US
Practice Address - Phone:505-828-0232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-160225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA-160OtherPHYSICAL THERAPIST ASST