Basic Information
| Provider Information | |||||||||
| NPI: | 1568521540 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | LONNIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2091 BOX BUTTE AVE | ||||||||
| Address2: | STE 500 | ||||||||
| City: | ALLIANCE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 693014456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3086232139 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2107 BOX BUTTE AVE | ||||||||
| Address2: | |||||||||
| City: | ALLIANCE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 693014415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3087627244 | ||||||||
| FaxNumber: | 3087626657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 03/12/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 762 | NE | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00165962 | 01 | RR MEDICARE - SFC | OTHER | 38772 | 01 | NE | BCBSNE | OTHER | 970016869 | 01 | RR MEDICARE - BBGH | OTHER | 506729276 | 05 | NE | MEDICAID |