Provider Demographics
NPI:1972303709
Name:EVERSON, GRANT
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:EVERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:942 SPRING PARK LN
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7304
Mailing Address - Country:US
Mailing Address - Phone:770-778-3362
Mailing Address - Fax:
Practice Address - Street 1:5900 LAKE ELLENOR DR STE 150
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4663
Practice Address - Country:US
Practice Address - Phone:407-393-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program