Provider Demographics
NPI:1487201018
Name:GRANT, VERA (PAC)
Entity type:Individual
Prefix:
First Name:VERA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 COLE ST FL 1
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-3504
Mailing Address - Country:US
Mailing Address - Phone:360-802-5032
Mailing Address - Fax:360-802-5039
Practice Address - Street 1:1818 COLE ST FL 1
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3504
Practice Address - Country:US
Practice Address - Phone:360-802-5032
Practice Address - Fax:360-802-5039
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61114885363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2173403Medicaid