Provider Demographics
NPI:1992345045
Name:GRANNER, MATTHEW JOSEPH
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:GRANNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 GENE ADAMS RD
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-8146
Mailing Address - Country:US
Mailing Address - Phone:731-514-3708
Mailing Address - Fax:
Practice Address - Street 1:2035 SAINT JOHN AVE
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2247
Practice Address - Country:US
Practice Address - Phone:316-619-8257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant