Provider Demographics
NPI:1255011813
Name:GRAHAM, BRENT
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49427 TULLOS RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70438-3855
Mailing Address - Country:US
Mailing Address - Phone:985-515-9751
Mailing Address - Fax:
Practice Address - Street 1:15770 PAUL VEGA MD DR STE 108A
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1475
Practice Address - Country:US
Practice Address - Phone:985-230-1870
Practice Address - Fax:985-230-7461
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA231115363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health