Provider Demographics
NPI:1962441642
Name:GRAHAM, MARIE E (CRNP)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:E
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 GARRETT RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-2940
Mailing Address - Country:US
Mailing Address - Phone:610-626-0940
Mailing Address - Fax:610-626-7615
Practice Address - Street 1:3400 GARRETT RD
Practice Address - Street 2:SUITE A
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-2940
Practice Address - Country:US
Practice Address - Phone:610-626-0940
Practice Address - Fax:610-626-7615
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP004825C207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA020211K9LMedicare ID - Type Unspecified
PAS64599Medicare UPIN