Provider Demographics
NPI:1174537849
Name:GRANDGENETT, JOHN R (APRN)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
Last Name:GRANDGENETT
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1021 N 27TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68503-1803
Mailing Address - Country:US
Mailing Address - Phone:402-476-1455
Mailing Address - Fax:402-476-1670
Practice Address - Street 1:3100 N 14TH ST STE 201
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-2134
Practice Address - Country:US
Practice Address - Phone:402-476-1455
Practice Address - Fax:402-476-1670
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE110342207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47074554413Medicaid
NE271948Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID
NE47074554413Medicaid