Provider Demographics
NPI:1053371591
Name:GRANDNER, DANIELLE MARIE (PA)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:GRANDNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 PETER AVE
Mailing Address - Street 2:SIDE APT
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306
Mailing Address - Country:US
Mailing Address - Phone:718-873-5574
Mailing Address - Fax:
Practice Address - Street 1:27 NEW DORP LN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-2349
Practice Address - Country:US
Practice Address - Phone:718-667-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010866363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant