Provider Demographics
NPI:1326618166
Name:GRAHAM, JUSTIN WILLIAM (CRNA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WILLIAM
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 S 192ND CT UNIT 108
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-3304
Mailing Address - Country:US
Mailing Address - Phone:308-631-8533
Mailing Address - Fax:
Practice Address - Street 1:635 N 152ND CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-1801
Practice Address - Country:US
Practice Address - Phone:308-631-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE75076163WC0200X
NE101710367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine