Provider Demographics
NPI:1740830637
Name:GRAHAM, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
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:PO BOX 2928
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2928
Mailing Address - Country:US
Mailing Address - Phone:425-207-5155
Mailing Address - Fax:
Practice Address - Street 1:2923 E 29TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-4811
Practice Address - Country:US
Practice Address - Phone:888-227-3312
Practice Address - Fax:509-227-7070
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 390200000X
WAPA61595338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program