Provider Demographics
NPI:1528382744
Name:LAURISTON, GRAEME (PT, DPT)
Entity Type:Individual
Prefix:
First Name:GRAEME
Middle Name:
Last Name:LAURISTON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 E ROSE GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4605
Mailing Address - Country:US
Mailing Address - Phone:480-449-9000
Mailing Address - Fax:480-449-9200
Practice Address - Street 1:2629 E ROSE GARDEN LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4605
Practice Address - Country:US
Practice Address - Phone:480-449-9000
Practice Address - Fax:480-449-9200
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10352PT225100000X
FLPT23805225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist