Provider Demographics
NPI:1225456304
Name:RACHAL, GRAHAM WAYNE (FNP)
Entity Type:Individual
Prefix:
First Name:GRAHAM
Middle Name:WAYNE
Last Name:RACHAL
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 E BERT KOUNS INDUSTRIAL LOOP STE 300
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-6000
Mailing Address - Country:US
Mailing Address - Phone:318-798-4488
Mailing Address - Fax:318-798-4672
Practice Address - Street 1:1455 E BERT KOUNS INDUSTRIAL LOOP STE 300
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5634
Practice Address - Country:US
Practice Address - Phone:318-798-4488
Practice Address - Fax:318-798-4672
Is Sole Proprietor?:No
Enumeration Date:2014-04-04
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID63614363LF0000X
LAAP07641363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2367994Medicaid
ID1225456304Medicaid