Active NPI
Wiley Grantham IV
- Physical Therapy Assistant
- Lake City, FL
National Provider Identifier
1619583689
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- 26541
- Practice address
- 560 SW McFarlane Ave
Lake City, FL 32025-5614 - Phone
- (386) 758-4777
- NPI assigned
- Sep 16, 2020
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | 26541 | FL | Primary |
Addresses
Primary practice location
560 SW McFarlane Ave
Lake City, FL 32025-5614
Mailing address
438 SE Lillian Loop Apt 103
Lake City, FL 32025-7248
Phone (386) 965-7461
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 26541 | FL | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1600214400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1600214400000",
"number": "1619583689",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "438 SE LILLIAN LOOP APT 103",
"city": "LAKE CITY",
"state": "FL",
"postal_code": "320257248",
"telephone_number": "386-965-7461"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "560 SW MCFARLANE AVE",
"city": "LAKE CITY",
"state": "FL",
"postal_code": "320255614",
"telephone_number": "386-758-4777"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GRANTHAM",
"first_name": "WILEY",
"name_prefix": "Mr.",
"name_suffix": "IV",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2020-09-16",
"last_updated": "2020-09-16",
"certification_date": "2020-09-10",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "FL",
"license": "26541",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Lake City, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 16, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.