Healthcare Provider Details

I. General information

NPI: 1043706856
Provider Name (Legal Business Name): STEPHANIE GRAHAM PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2018
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 BANNOCK ST
DENVER CO
80204-4597
US

IV. Provider business mailing address

6774 KLINE ST
ARVADA CO
80004-1548
US

V. Phone/Fax

Practice location:
  • Phone: 303-602-3899
  • Fax: 303-602-3902
Mailing address:
  • Phone: 630-440-3899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.0005464
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: