Provider Demographics
NPI:1649243494
Name:GRAHAM, MOIRA E (PNP)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:E
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1470
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78853-1470
Mailing Address - Country:US
Mailing Address - Phone:830-773-8917
Mailing Address - Fax:830-773-1892
Practice Address - Street 1:1117 W DE LA ROSA ST
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840
Practice Address - Country:US
Practice Address - Phone:830-768-4800
Practice Address - Fax:830-768-4844
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX633353163W00000X
TXA109911363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1411407-08Medicaid