Healthcare Provider Details

I. General information

NPI: 1043307192
Provider Name (Legal Business Name): SUSAN GRAHAM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 VIVIAN ST
LONGMONT CO
80501-3217
US

IV. Provider business mailing address

1120 E ELIZABETH ST STE 2
FORT COLLINS CO
80524-4044
US

V. Phone/Fax

Practice location:
  • Phone: 800-628-7828
  • Fax:
Mailing address:
  • Phone: 970-493-9193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1819
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: