Provider Demographics
NPI:1215934070
Name:GRANITSAS, JOAN (CRNP)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:GRANITSAS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 BEACH ST
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-3143
Mailing Address - Country:US
Mailing Address - Phone:781-289-5057
Mailing Address - Fax:781-289-4485
Practice Address - Street 1:280 BEACH ST
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3143
Practice Address - Country:US
Practice Address - Phone:781-289-5057
Practice Address - Fax:781-289-4485
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA214641208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0350231Medicaid
MANP9820OtherBCBS
MANP9820Medicare ID - Type Unspecified