Provider Demographics
NPI:1932230190
Name:SMITH, GRAHAM J
Entity Type:Individual
Prefix:
First Name:GRAHAM
Middle Name:J
Last Name:SMITH
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 210805
Mailing Address - Street 2:
Mailing Address - City:AUKE BAY
Mailing Address - State:AK
Mailing Address - Zip Code:99821-0805
Mailing Address - Country:US
Mailing Address - Phone:907-364-3584
Mailing Address - Fax:
Practice Address - Street 1:3100 CHANNEL DR
Practice Address - Street 2:SUITE 314
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7814
Practice Address - Country:US
Practice Address - Phone:907-364-3584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPCG245374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPCG245Medicaid