Basic Information
| Provider Information | |||||||||
| NPI: | 1780895755 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRINER | ||||||||
| FirstName: | DEVAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 300 W STE 303 | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017029191 | ||||||||
| FaxNumber: | 8016062705 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 N 300 W STE 303 | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017029191 | ||||||||
| FaxNumber: | 8016062705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 03/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2082S0099X | 374716-1205 | UT | N | Allopathic & Osteopathic Physicians | Plastic Surgery | Plastic Surgery Within the Head and Neck | 2086S0122X | 374716-1205 | UT | N | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 208200000X | 374716-1205 | UT | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 103I933353 | 01 | MEDICARE PTAN | OTHER |