Provider Demographics
NPI:1356401574
Name:GRAHAM, GREGG TRAVIS (FNP)
Entity type:Individual
Prefix:
First Name:GREGG
Middle Name:TRAVIS
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-2090
Mailing Address - Fax:
Practice Address - Street 1:354 COPPERFIELD BLVD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2402
Practice Address - Country:US
Practice Address - Phone:704-786-5122
Practice Address - Fax:704-782-8279
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011714363LF0000X
FLARNP9332853363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0397730026OtherNSC#
FL004338900Medicaid
NC0397730026OtherNSC#