Basic Information
| Provider Information | |||||||||
| NPI: | 1912064577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 S 13TH ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603362178 | ||||||||
| FaxNumber: | 3603361674 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S 13TH ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603362178 | ||||||||
| FaxNumber: | 3603361674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 03/15/2012 | ||||||||
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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 | 207Y00000X | 47898-020 | WI | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 242010 | MA | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207YX0905X | MD60187241 | WA | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | 2082S0099X | MD60187241 | WA | N | Allopathic & Osteopathic Physicians | Plastic Surgery | Plastic Surgery Within the Head and Neck | 208600000X | MD60187241 | WA | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0122X | MD60187241 | WA | N | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0271141 | 01 | WA | LABOR AND INDUSTRIES | OTHER | 2009841 | 05 | WA | MEDICAID | P00700778 | 01 | RAILROAD MEDICARE | OTHER |