Provider Demographics
NPI:1659957132
Name:GRAHAM, GEOFFREY LEE (NP)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:LEE
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:615 N BONITA AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3623
Practice Address - Country:US
Practice Address - Phone:850-769-1511
Practice Address - Fax:850-416-6159
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-23
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11012283363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily