Provider Demographics
NPI:1104998541
Name:GRANT-ACQUAH, JULIE N (PA-C)
Entity type:Individual
Prefix:MS
First Name:JULIE
Middle Name:N
Last Name:GRANT-ACQUAH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JULIE
Other - Middle Name:N
Other - Last Name:DESAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-455-6330
Mailing Address - Fax:
Practice Address - Street 1:9898 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1205
Practice Address - Country:US
Practice Address - Phone:858-455-6330
Practice Address - Fax:858-455-5408
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23005363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1104998541Medicaid
WI1104998541Medicaid
WI680860619Medicare PIN