Provider Demographics
NPI:1730317728
Name:GRAHAM, NICHOLAS JAMES (IDMT)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:JAMES
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 W.DESKA DR APT 601
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99224
Mailing Address - Country:US
Mailing Address - Phone:360-701-1192
Mailing Address - Fax:
Practice Address - Street 1:2504 S.CHICAGO ST
Practice Address - Street 2:
Practice Address - City:FAIRCHILD AFB
Practice Address - State:WA
Practice Address - Zip Code:99011
Practice Address - Country:US
Practice Address - Phone:509-657-5414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians