Provider Demographics
NPI:1699796052
Name:GRANDIA, CONNIE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIE
Last Name:GRANDIA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:MARIE
Other - Last Name:GRANDIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2200 NW 26TH ST
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-5503
Mailing Address - Country:US
Mailing Address - Phone:507-451-1120
Mailing Address - Fax:507-444-6287
Practice Address - Street 1:134 SOUTHVIEW ST
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-3241
Practice Address - Country:US
Practice Address - Phone:507-451-1120
Practice Address - Fax:507-444-6287
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9651363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN767608500Medicaid
P84047Medicare UPIN
MN767608500Medicaid