Provider Demographics
NPI:1821381179
Name:GRAHAM, DAVID (FNP-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3256 CUB CT
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-9357
Mailing Address - Country:US
Mailing Address - Phone:925-354-3280
Mailing Address - Fax:
Practice Address - Street 1:701 E CHANNEL ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2628
Practice Address - Country:US
Practice Address - Phone:209-944-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA742829363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily