Provider Demographics
NPI:1558554188
Name:GRAHEK, GREGORY CHARLES (NP-BC)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:CHARLES
Last Name:GRAHEK
Suffix:
Gender:M
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2728
Mailing Address - Country:US
Mailing Address - Phone:719-671-4629
Mailing Address - Fax:719-583-1292
Practice Address - Street 1:1925 E ORMAN AVE STE A535
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3559
Practice Address - Country:US
Practice Address - Phone:719-564-0450
Practice Address - Fax:719-564-1659
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5441363LF0000X
CO173720-5414363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO333409528Medicaid
CORXN 08-123OtherSTATE RXN
MG 1822685OtherDEA
COC811179Medicare PIN