Basic Information
| Provider Information | |||||||||
| NPI: | 1295194629 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANGE | ||||||||
| FirstName: | RYAN | ||||||||
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| Credential: | P.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12127B HWY 14 N | ||||||||
| Address2: | STE 5 | ||||||||
| City: | CEDAR CREST | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870089499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052815180 | ||||||||
| FaxNumber: | 5052815320 | ||||||||
| Practice Location | |||||||||
| Address1: | 1851 OLD HIGHWAY 66 UNIT 1 | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052862396 | ||||||||
| FaxNumber: | 5052862398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2016 | ||||||||
| LastUpdateDate: | 04/14/2016 | ||||||||
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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 | 363AM0700X | PA 2016-0016 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.