Provider Demographics
NPI:1528438140
Name:GRANGE, JAMIE COY (PA-C)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:COY
Last Name:GRANGE
Suffix:
Gender:F
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 1:2245 N 400 E
Mailing Address - Street 2:STE 301
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341
Mailing Address - Country:US
Mailing Address - Phone:435-753-7880
Mailing Address - Fax:
Practice Address - Street 1:2245 N 400 E
Practice Address - Street 2:STE 301
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1892
Practice Address - Country:US
Practice Address - Phone:435-753-7880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-25
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT95341561206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical