Provider Demographics
NPI:1811947344
Name:GRAHAM, ADAM W (PA)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:W
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12499 CLAIMSTAKE CT
Mailing Address - Street 2:
Mailing Address - City:LOLO
Mailing Address - State:MT
Mailing Address - Zip Code:59847-9435
Mailing Address - Country:US
Mailing Address - Phone:406-493-8269
Mailing Address - Fax:
Practice Address - Street 1:12499 CLAIMSTAKE CT
Practice Address - Street 2:
Practice Address - City:LOLO
Practice Address - State:MT
Practice Address - Zip Code:59847-9435
Practice Address - Country:US
Practice Address - Phone:406-493-8269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5703835-1206363A00000X, 363AM0700X
MTMT 503363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
80105OtherPEHP #
224848OtherALTIUS #
13228OtherUNIVERSITY HEALTH PLANS
ID807004900Medicaid
NV100505177Medicaid
13228OtherUNIVERSITY HEALTH PLANS
ID807004900Medicaid