Provider Demographics
NPI:1104908748
Name:GRANZOW, PAUL R (PA-C)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:GRANZOW
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602148
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2148
Mailing Address - Country:US
Mailing Address - Phone:828-286-9036
Mailing Address - Fax:828-286-1079
Practice Address - Street 1:181 DANIEL RD
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-7151
Practice Address - Country:US
Practice Address - Phone:828-286-9036
Practice Address - Fax:828-286-1079
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101884363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101814Medicaid
NC1104908748Medicaid
970027367OtherMEDICARE RAILROAD
970027367OtherMEDICARE RAILROAD
NCS77832Medicare UPIN
NC1104908748Medicaid
NC2751292Medicare PIN