Provider Demographics
NPI:1104209436
Name:GRAHAM, JUSTIN (AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1685 LEE RD STE 210
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2235
Mailing Address - Country:US
Mailing Address - Phone:407-303-6729
Mailing Address - Fax:407-628-2037
Practice Address - Street 1:601 E ROLLINS ST
Practice Address - Street 2:TRI-COUNTY NEUROLOGY
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1248
Practice Address - Country:US
Practice Address - Phone:407-303-6729
Practice Address - Fax:407-628-2037
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9254942363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner