Provider Demographics
NPI:1336582535
Name:GRAHAM, JONATHAN DANIEL (CRNA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DANIEL
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 BROOKDALE DR
Mailing Address - Street 2:ANESTHESIA DEPT
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-4107
Mailing Address - Country:US
Mailing Address - Phone:704-878-7609
Mailing Address - Fax:
Practice Address - Street 1:701 N 1ST ST
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-0001
Practice Address - Country:US
Practice Address - Phone:217-788-3755
Practice Address - Fax:217-788-7071
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010329367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
92431OtherNBCRNA