Provider Demographics
NPI:1679954093
Name:GRANNEMAN, PATRICK (DO)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:GRANNEMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N 25TH ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-9069
Mailing Address - Country:US
Mailing Address - Phone:417-581-3548
Mailing Address - Fax:417-581-6164
Practice Address - Street 1:505 N 25TH ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721
Practice Address - Country:US
Practice Address - Phone:417-581-3548
Practice Address - Fax:417-581-6164
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018014589207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine