Provider Demographics
NPI:1669484879
Name:GRAHAM, ALEXANDER JAMES (ATC)
Entity Type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:JAMES
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 MINNEHAHA AVE W
Mailing Address - Street 2:209
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1256
Mailing Address - Country:US
Mailing Address - Phone:612-618-2661
Mailing Address - Fax:
Practice Address - Street 1:516 15TH AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0130
Practice Address - Country:US
Practice Address - Phone:612-625-2827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer