Basic Information
| Provider Information | |||||||||
| NPI: | 1710591516 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | SARA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 45443 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841450443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042021032 | ||||||||
| FaxNumber: | 9043764036 | ||||||||
| Practice Location | |||||||||
| Address1: | 10898 BAYMEADOWS RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322565838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045195338 | ||||||||
| FaxNumber: | 9043907481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2020 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9113596 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.