Provider Demographics
NPI:1417926528
Name:GRAHAM, TRAVIS S (MD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:S
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 INA AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-9825
Mailing Address - Country:US
Mailing Address - Phone:307-578-2372
Mailing Address - Fax:
Practice Address - Street 1:707 SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3409
Practice Address - Country:US
Practice Address - Phone:307-578-2372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7334A2085R0202X
CO435922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYP00324453OtherRR MEDICARE
WY121621000Medicaid
COCO300926Medicare PIN
WY121621000Medicaid
COP00695840Medicare PIN
COCO300912Medicare PIN
WYP00324453OtherRR MEDICARE