Basic Information
| Provider Information | |||||||||
| NPI: | 1912104431 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANVILLE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | LESLIE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 626 APACHE MOUNTAIN LN | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786335434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129439847 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4945 WILLIAMS DR | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786332008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128190500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| LastUpdateDate: | 04/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA06979 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.