Provider Demographics
NPI:1447586987
Name:GRAHAM, NATHANIEL LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:LEE
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 E MAIN ST
Mailing Address - Street 2:PO BOX 8674
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5066
Mailing Address - Country:US
Mailing Address - Phone:507-385-4070
Mailing Address - Fax:
Practice Address - Street 1:1421 PREMIER DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6076
Practice Address - Country:US
Practice Address - Phone:507-385-4070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-18
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410003280Medicare PIN