Provider Demographics
NPI:1245778182
Name:GRAHAM, NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 W INNES ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-2574
Mailing Address - Country:US
Mailing Address - Phone:704-636-5626
Mailing Address - Fax:704-636-5641
Practice Address - Street 1:1401 W INNES ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2574
Practice Address - Country:US
Practice Address - Phone:704-636-5626
Practice Address - Fax:704-636-5641
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07063363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical