Healthcare Provider Details

I. General information

NPI: 1558554188
Provider Name (Legal Business Name): GREGORY CHARLES GRAHEK NP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2007
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 N GREENWOOD ST STE 208
PUEBLO CO
81003-2656
US

IV. Provider business mailing address

1619 N GREENWOOD ST STE 208
PUEBLO CO
81003-2656
US

V. Phone/Fax

Practice location:
  • Phone: 719-564-4336
  • Fax: 719-561-8469
Mailing address:
  • Phone: 719-671-4629
  • Fax: 719-561-8469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5441
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number173720-5414
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: