Provider Demographics
NPI:1396721189
Name:GRANT, EMILYE JESSICA (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:EMILYE
Middle Name:JESSICA
Last Name:GRANT
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3803
Mailing Address - Country:US
Mailing Address - Phone:217-464-1750
Mailing Address - Fax:217-464-1469
Practice Address - Street 1:1750 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3803
Practice Address - Country:US
Practice Address - Phone:217-464-1750
Practice Address - Fax:217-464-1469
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA30148363AM0700X
LAPA200169363A00000X
IL085005568363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1027626Medicaid
LA1027626Medicaid