Provider Demographics
NPI:1508816570
Name:LAND, GRANT THOMAS (PA-C)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:THOMAS
Last Name:LAND
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6175 NEWTON DR NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2690
Mailing Address - Country:US
Mailing Address - Phone:770-787-6900
Mailing Address - Fax:770-787-6962
Practice Address - Street 1:1445 OLD MCDONOUGH HWY SE, SUITE E
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-7788
Practice Address - Country:US
Practice Address - Phone:770-922-9222
Practice Address - Fax:770-504-6318
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004108207Q00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003200095AMedicaid
GA004108OtherPA LICENSE NUMBER
GAQ68555Medicare UPIN